GABRIEL COUSENS, M.D.

HEALTH INTAKE FORM

NEW CLIENT APPLICATION

Please complete and submit the Health Intake Form below along with a non-refundable $50 application fee to be considered as a client of Dr. Cousens. Once your application is complete, we will email you at the email address you provide below with a decision. If approved, you will be guided on how to proceed forward with completing your payment and arranging your appointment time. Please allow up to 7 business days for application processing.