Elder Bloom Consultation Call 1 hour // $300 Please complete the form and Riverside Care Advisors will get back to you shortly via email with a date & time for a Consultation Call. Name * First Name Last Name Phone * (###) ### #### Email * Please provide three days and corresponding times you are available within the next two weeks to schedule your Consultation. What is the client's current address? * What is the client's date of birth? * MM DD YYYY Past medical history: * Past surgical history: Please describe the symptoms and concerns you are looking to address on this consultation: Please list or email to us current medications: * Does the client have any food or drug allergies? * YES NO Current approximate height and weight: Does the client smoke tobacco? * YES NO Does the client drink alcohol? * YES NO Does the client currently use cannabis? * YES NO Has the client had any side effects from cannabis use? If yes, please describe. * Please list the client's primary care provider with contact information: * Is the client currently under the care of a mental health provider? * YES NO Is the client having pain? * YES NO Please tell us about the goals of the consult and any other important details related: Privacy Policy * Protecting your private information is a priority to Riverside Care Advisors. This Statement of Privacy applies to www.riversidecareadvisors.com, and Riverside Care Advisors, and governs data collection and usage. By using this business website you consent to the data practices described in this statement. Riverside Care Advisors, LLC does not collect any personal data unless you, the user of the website, voluntarily provides personal information. You may be asked for personal information if you elect to use or inquire about our services. This information may include: 1. Email address 2. Cell phone number 3. address 4. credit card information when scheduling for a service to be provided. Riverside Care Advisors, LLC uses this information for communication with you in relation to the services you are requesting. Riverside Care Advisors, LLC may also gather additional personal or non-personal information in the future. Riverside Care Advisors, LLC does not share or sell any personal information collected to share or sell to third parties. Riverside Care Advisors, LLC may share information provided by the user to Riverside Care Advisor employees to provide services to you. They are required to maintain confidentiality of all information. I have read and agree to the terms above. Terms & Conditions * I understand I am 100% responsible for educating myself and understanding the state laws and/or jurisdictions in which I reside in regard to use of cannabinoids. I have read and agree to the terms above. Thank you! Riverside Care Advisors will be getting back to you shortly via email with a date and time for your call.
