Name *

First Name

Last Name

Parent/Guardian Name (if patient is a minor)

First Name

Last Name

Birthday *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Dr. Bardi requires that all out of state patients be seen in person once per year. Typically this is the second appointment, after the initial phone consult. Do you agree to this? *

Yes! Can't wait to explore Seattle.

Absolutely - I am excited to get hands on treatment.