APPLICATION to Schedule Functional Medicine Appointment | Dr. Dishman

Are you a resident of the United States?*
- Yes, I am resident of the US.
Are you willing to come to one of Dr. Dishman' offices in Raleigh, NC or Bend, OR for the Initial New Patient Appointment (Phase One: Case Review)?*
- Yes, I am willing to travel to Raleigh, NC or Bend, OR for the Initial 1st Appointment (Phase One: Case Review) appointment with Dr. Dishman.

Where will you be visiting us?*
About You
Name*
First Last
Date of Birth*
Month
Day
Year
Gender*
- Male
- Female
Contact Information
Email*
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
What is the health challenge you're seeking help with?*
- Fertility Care
- Autoimmunity
- Hormone Health
- Gut Health: IBS, IBD (Diarrhea, Constipation, Bloating, etc)
- SIBO
- Leaky Gut
- Other
Other health challenges you're seeking help with?
What treatment(s) have you tried?*
Name
This field is for validation purposes and should be left unchanged.

North Carolina Registration + Waitlist Info