Name *

First Name

Last Name

Phone

(###)

###

####

Please Note: *

This contact form is only for requesting a Phone or Skype Consult. For all other needs, please call the office.

We make every effort to call you back in a timely manner at the number you have provided (if during business hours).

If you have not heard back in a timely manner, or need immediate assistance, please call the office. We may unavailable for the day or busy with other tasks.

If this is an EMERGENCY, please go to the emergency room or urgent care. Thank you.

Acknowledgment

I understand that Ayurveda is not intended to diagnose, treat, mitigate, cure or prevent a specific disease. I understand that the Ayurveda therapies, education and recommendations I receive from Dr. Grasser are intended to be complimentary and in addition to traditional western medical preventative care, diagnosis and treatment. This non-secure form submission is for appointment inquiry only. It cannot be used for providing personal health information or asking health questions. I understand that submitting any health information by this medium is not protected by the Health Insurance Portability and Accountability Act (HIPAA) and Dr. Eric Grasser or his business will not be responsible if I provide such information. By clicking accept, I acknowledge that I have read and understand the above.

I agree and understand