New Client Form

This form will help you better understand how we work with our clients. We want you to understand how the services we provide stand out and make sure they will be a good fit your your individual health needs and wellness goals.

    Are you interested in a health and wellness consultation with Tony?

    Are you planning to travel to our Wellness Center in Newburgh, NY for the first appointment? (Follow ups can be done by phone.)

    Are you interested in a holistic nutrition consultation with Matt? (in person or remote)

    We recommend you be under the care of a Primary Care Physician as well who can manage day-to-day routine care. Do you currently work with a Primary Care Physician (PCP)?

    Please fill out your contact information below and let us know what your main health concerns are. We will get back to you within 24-72 hours to schedule your appointment.

    Your First Name (required)

    Your Last Name (required)

    Your Email (required)

    Phone Number (required)

    Street Address (required)

    Address Line 2

    State/Province (required)

    Zip/Postal Code (required)

    Country (required)

    Top 3 Health Concerns

    Other Comments

    How did you hear about The Breath of Life Wellness Center?