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Contact
646.627.8000
bridget@drbojana.com

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Fax
646.368.8019

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245 5th Avenue
3rd floor
NY, NY 10016

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We are licensed in New York, Connecticut, California, Florida, and New Jersey.

Patient Application Form

Name: Dr. Bojana Jankovic Weatherly
Address: New York City, NY, 10016
Telephone: 646.627.8000

Company

First Name *

Last Name *

Date of Birth *

Address *

City *

State *

Zip *

Phone *

Email *

What are your top 3 challenges that you would like us to help you overcome?

Why are these health goals important to you? *

What is stopping you from accomplishing these goals? *

If you were to wake up tomorrow without these challenges, how would your life be different? *

What are the top factors that motivate you to invest in these problems? *

Do you have a strong support system to help you in this journey? (e.g., family, friends, significant other) *

On a scale of 1-10, how coachable do you feel you are? *

1 being NOT very coachable and 10 being very coachable.

What are the characteristics you value in a doctor-patient partnership? *

How do you best learn? (e.g., reading materials, videos, podcasts) *

Who else have you worked with? *

Functional Medicine Practitioner

Integrative Medicine Physician

Medical or Osteopathic Doctor

Naturopathic Doctor

Traditional Chinese Medicine Practitioner

Nutritionist

Personal Trainer

Chiropractor

Personal Development Coach

Other:

What functional lab testing have you had done? *

Functional Stool Testing

Organic Acids Testing

Genetic or Genomic Testing

Hormone Testing

Heavy Metal Testing

None

Other

Considering your past treatments, what would you like to improve or do differently moving forward? *

Are you willing to do what is necessary to improve your health (dietary changes, lab testing and/or lifestyle modifications)? *

Are you willing to invest in a personalized health plan that would address your health and wellness goals and have long lasting effects? *

Would you be interested in joining a Facebook group hosted by our practice? The purpose of the group is to share health and wellness information and provide you with an opportunity to ask general questions about healthy lifestyle and nutrition. *

Yes No

How did you hear about us? *

What are your top three health and wellness questions you would like us to address in our future content? *

Email Consent

Add me to Dr. Bojana's health letter. I want to receive the latest health news, practical wellness tips and recipes from Dr. Bojana. I understand that my email will not be shared with anyone, and that I can opt out anytime.

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