New Patient Inquiry

1
I have read and understand the "New Patients" page of the Motivated Medicine website.* This field is required.New Patient Information - Motivated Medicine
YesNo
2
I understand that Motivated Medicine clinicians are out-of-network with all insurance companies.* This field is required.Our clinicians are opted out of Medicare and patients with Medicare may not submit for Medicare reimbursement.
YESNO
3
I understand that Motivated Medicine's current pricing is as follows:* This field is required.NEW PATIENT APPOINTMENT (60-90 MINUTES) Dr. Zielsdorf | $695 NP/PA | $485 FIRST FOLLOW UP / EXTENDED FOLLOW UP (UP TO 55 MINUTES) Dr. Zielsdorf | $465 NP/PA | $345 STANDARD / FOLLOW UP (UP TO 40 MINUTES) Dr. Zielsdorf | $385 NP/PA | $285 Pricing Subject to change at any time.
YESNO
4
I understand that in order to be considered an "active" patient of Motivated Medicine I MUST (1) establish care in person at the Motivated Medicine Office in West Chicago, Illinois, and (2) be seen in person at the office annually.* This field is required.
YesNo
5
I understand that telehealth appointments are only available to patients when they are physically in the state of Illinois.* This field is required.
YesNo
6
Patient Legal Name* This field is required.Must be your legal name (can add nickname in parenthesis after your legal name)
First Name
Last Name
7
Name of legal guardian completing form and relationship to patient (if completing for a minor or someone for whom you have guardianship)
8
Gender* This field is required.
9
Pronouns
10
Phone Number* This field is required.
Please enter a valid phone number.
11
Email* This field is required.By entering your email address you understand that Motivated Medicine will be contacting you via email about future appointments, confirmations, policies, and offering updates.
example@example.com
Confirm Email
12
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
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Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
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Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
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eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
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Ukraine
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United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
13
Patient Date of Birth* This field is required.
Date
Month
Day
Year
14
How did you learn about Motivated Medicine?* This field is required.
Facebook
Referring Clinician
Existing Motivated Medicine Patient
Other
15
Please list the specific condition(s) and/or symptoms you are seeking treatment for from Motivated Medicine?* This field is required.Please limit your response to a brief description that includes symptoms that are inhibiting your daily function, and any official or self diagnoses. If accepted as a patient, you will complete a detailed health history form.
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16
How long have you been experiencing these issues?
Less than a year
1 - 3 Years
3 - 5 Years
5+ Years
17
Please list all workups and clinicians/specialists you have seen in the past.* This field is required.Please limit your response to a brief description. If accepted as a patient, you will complete a detailed health history form.
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18
What are you hoping to achieve with the help of Motivated Medicine that you haven't with previous treatment?* This field is required.Check as many as apply. If "other" selected, please type in the response.
determine root cause(s)
optimal thyroid hormone management
balancing hormones
overall wellbeing
improvement in symptoms
more energy
Other
19
Please indicate if you've been diagnosed with any other current and/or previous medical conditions* This field is required.Check as many as apply. If "other" selected, please type in the response.
heart disease
hypertension
cancer
diabetes
stroke
kidney disease
psychiatric disorders
liver disease
blood clotting disorder (other than MTHFR)
MTHFR (either mutation)
Other
20
What medications (including dosages), vitamins, and supplements are you currently taking?* This field is required.
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21
If you have a preference for which clinician you'd like to see, please let us know below:Please note that although we will attempt to pair you with your preferred clincian, we prioritize matching the best clinician to your individual medical needs.
22
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