The Pure Rx Michigan | True-Rife Patient Form

Please fill out the form prior to your appointment to expedite your wait time. Thank you.

True-Rife Patient Form

Name
This field is for validation purposes and should be left unchanged.
Name*
First Last
How did you hear about us?*
e.g.. Google Search, Friend Referral, Yelp, etc.
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Gender*
Date of Birth*
MM slash DD slash YYYY
Phone*
Email*
Have you ever had True-Rife? When?
Why Have you chosen True-Rife?
Please list all current medications and supplements
CAPTCHA

Thank you for completing your true-rife patient form. We understand that it takes a considerable amount of time to complete this form and appreciate your patience. This valuable information will help guide Dr. Mathew in better understanding you as he creates your individualized health plan.

True-Rife Patient Form

True-Rife Patient Form

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