RestoreU METHOD

New Patient Sign-up Form

Use this form to register a patient for cognitive impairment therapy with one of our partner clinics. You will need your clinic's primary phone number to register.

First Name*

Last Name*

Date of Birth *

Month	Day	Year

Phone number

E-mail Address

Sex

Highest education level patient has achieved

Blood Pressure
/

Date

Height (in)

Date

Weight (lbs)

Date

Assessment *

Clinic Primary Phone #*

* denotes a required field.