Isaac Health registration

1

Are you here for yourself or a family member?

Myself

Family member

2

What brings you to Memory Clinic?Check all that apply

Prevention of Alzheimer's or memory loss

Assessing / monitoring of memory function

Training memory / building up cognitive reserve

Assessing my risk of developing dementia

3

List any particular concerns you have, if any

4

What is your name?The name of the person who is being registered

First Name

Last Name

5

Email* This field is required.

example@example.com

6

Phone Number* This field is required.

Please enter a valid phone number.

7

Your date of birth

Date

8

Where are you based?

United States

Rest of World

9

Which US State are you based in?

10

Which country are you based in?

11

How did you hear about us

12

Which membership option are you interested in (you can always upgrade)

Free trial (free initial consultation and memory self-assessments)

Full membership, paid ($50 per month, full access to medical consultations and neuropsychological evaluations)

Full membership with insurance or Medicare coverage, paid ($10 per month, as per full membership)

13

Now book your free initial consultation appointmentYou can also skip this step for now and click submit if you prefer