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DO YOU NEED CHELATION THERAPY?

LET'S FIND OUT




About you...

We're happy you found Chelation Doctors and/or the Affiliate Center you've chosen.  We strive to make this journey in the most seamless, efficient, and professional manner.  The medical staff at your treatment center will deliver chelation therapy services per our protocols and customized orders written and directed by our Advanced Chelation Providers.  

The following are a series of questions designed to confirm whether chelation therapy is right for you.  Although a large percentage of our population can benefit from chelation, there are some conditions where we need to either take some safety precautions and/or not recommend chelation at all.  

Questions in this section will be needed to register you as a client in our electronic medical record (CharmHealth) which will be the next step, should you decide to proceed with testing and/or chelation therapy treatments.
Last Name
This question is required
First Name
This question is required
What is your age?
This question is required
Date of birth
/
/
Please enter a valid date
Address
Street*
City/Suburb
State*
Zip/Post Code*
Country*
This question is required

Email address
Please enter a valid email


Phone number
(By providing a telephone number and submitting the form you are consenting to be contacted by SMS text message from Chelation Doctors LLC. Message frequency may vary. Message & data rates may apply. Reply STOP to opt out of further messaging. Reply HELP for more information. See our Privacy Policy)
This question is required
(By providing a telephone number and submitting the form you are consenting to be contacted by SMS text message from Chelation Doctors LLC. Message frequency may vary. Message & data rates may apply. Reply STOP to opt out of further messaging. Reply HELP for more information. See our Privacy Policy)
If you are established or coming through a Clinic or ChelationDoctors.com Affiliate Center please MAKE YOUR SELECTION  (if you selected NOT ESTABLISHED you will  complete next section starting at "CHELATION QUESTIONS AND MEDICAL HISTORY")?
Select...
This question is required
I am selecting the above Affiliate Center because...
Select...
This question is required


About your area...
*If you already selected a clinic or center above you may bypass this section and proceed to next section: "CHELATION QUESTIONS AND MEDICAL HISTORY"...

If there isn't yet a ChelationDoctors.com Affliate Center in your area, are you established with a clinic or provider in your area that our team could  approach to deliver your chelation treatments? 
Select...

City and State you are interested in getting Chelation Therapy in (ChelationDoctors.com is actively recruiting affiliate clinics to join our network)
If YES, would you be willing to share details of that provider or clinic here now?
Select...
Alternate clinic or provider that potentially could deliver your treatments in your area (name, city/state, website, phone number)



CHELATION QUESTIONS AND MEDICAL HISTORY
...and now for some targeted medical questions and other stuff... 

Have you ever had Chelation Therapy?
Yes
No
Please choose an answer
Are you concerned about any of these toxic metals?
Lead
Mercury
Cadmium
Arsenic
Aluminum
Nickel
Thallium
Other metals
I'm not sure but I think I've had exposures
This question is required
Has any doctor or medical provider ever tested you for toxic metals (please note that toxic or "heavy" metals testing is done with urine testing, including  "provocation" tests, along with bloodwork)?
Yes
No
I'm not sure
Other
This question is required
Have you had any toxic (heavy) metals testing in the past 3 months?
Yes
No
Please choose an answer
If yes, what type of testing was done?
Blood
Urine
Provoked urine testing (urine was collected for at least 6 hours after an IV chelator was   administered)
Hair
I'm not sure
Other
If yes, did results indicate any of these metals (select all that apply)?
Lead
Mercury
Cadmium
Nickel
Aluminum
Arsenic
Beryllium
Gadolinium
Chromium
I'm not sure
Other



Do you have a healthcare provider who supports Functional, Complementary, and/or Integrative Medicine including exploring chelation therapy as a treatment option?
Yes
No
If so, will you want us to communicate with your provider sending him/her clinic reports and updates (we'll get their contact info later)?
Yes
No

Are you currently, or in the past been under the care of a Functional, Integrative, or Complementary Medicine physician?
Yes
No
Please choose an answer
Please review the following and check any that may apply to you
Born before 1980 (high risk for chronic lead exposure)
Diet regularly includes large fish (tuna, swordfish, Mahi, shark) sushi, salmon
Tattoos
Smoke or chew tobacco
Dental metal fillings or "amalgam", past or present
Had lots of contrast radiologic or nuclear medicine studies
Chemotherapy
Radiation therapy
Lived near large factories, commercial farms, power plants
Regularly consume water or drinks packaged in plastic bottles
Gun enthusiast, handle firearms and ammunition, reload ammunition
Work in aerospace, engineering, or manufacturing
Work as a dentist, dental hygienist, or dental assistant
This question is required
If you have had dental metal fillings, past or present, have you had those metal fillings removed and replaced by a Biologic or Integrative Dentist??
Yes
No
Medical history, past or present (check all that apply) 
Coronary artery disease, angina, heart attacks, atherosclerosis
Peripheral vascular disease or "PAD"
Congestive heart failure and/or pulmonary edema
Diabetes, Pre-diabetes
Kidney disease (acute or chronic), dialysis (past or present)
Been on hemodialysis at any time
Dementia, memory
Parkinson's Disease
Stroke, or mini stroke
Implanted devices (pacemaker, prosthetic joints, hip, shoulder, spinal fusion, pins/rods, etc.)
Dental implants
Chronic fatigue, brain fog
Poor digestion
None of the above
This question is required
Do you have a "methylation" defect (MTHFR, a genetic defect that affects how atoms and molecules are processed in the body)?
Yes
No
I don't know
This question is required
Are you allergic to any of these chelators?
EDTA (sodium or disodium EDTA, calcium EDTA)
DMPS
DMSA
I have NO KNOWN ALLERGY to any of these chelators
I'm not sure
This question is required
About your travel history and plans, where you may be away from the clinic or center more than a week at a time  (important when considering longer treatment plans to make sure you have no extended interruptions)
Select...
This question is required


Do you have anything you wish to share or comment on  that we may not have addressed?
I understand that ChelationDoctors.com is a telemedicine based consultation service by A.C.A.M. (American College for Advancement in Medicine) certified Advanced Chelation Providers who will formulate a chelation therapy plan tailored to you.   I Understand that ChelationDoctors.com will coordinate the delivery of your chelation therapy via a network of authorized Affiliate Clinics in your area who will administer those treatments.   Chelation services pricing and fee structures are divided into ChelationDoctors.com services (consultations, monitoring, lab testing, supplements) and Affiliate Clinic Services (chelation infusions, additional IV infusions, e.g. ozone/chezone, glutathione, etc.) as formulated by the ChelationDoctors.com providers.  Our patients will thus have 2 accounts (one with ChelationDoctors.com and one with the Affiliate Clinic).  Pricing and estimated costs are available in the "Services" tab of ChelationDoctors.com  website and the Affiliate Clinics website.   I understand that all physician consultations and lab tests conducted by Chelation Doctors are paid directly to them, while the chelation infusion treatments are paid directly to the Affiliate Clinic. The pricing for the infusion series is determined by the Affiliate Clinic, but it should not exceed the pricing range set by ChelationDoctors.com. Your signature here does not infer any contract or other obligation.  It just means you've actually taken the time to read it
Sign here
  
This question is required
Submit


Submit now to send your form.

Your form will be promptly reviewed by our ChelationDoctors.com Intake Coordinator and you will soon be contacted with instructions to
BOOK YOUR LAB TESTING AND CONSULTATION.
Our best,
Let's Move Some Metal!
 