Contact — LongCOVIDDoc.com

New Patient Intake Form

For patients seeking ongoing care — insurance-based in MA/NE (Aetna, BCBS, Harvard Pilgrim), or self-pay in any licensed state. This gives the office everything needed to verify eligibility and reach out to schedule.

Unlicensed states: If you're outside MA, FL, MI, RI, PA, CT, NY, VT, NH, or ME, the Diagnostic Framework Consultation is available nationwide as a health-education service.

Insurance card privacy note: This form sends directly to the practice email over standard HTTPS. It is not a HIPAA-certified channel. By submitting, you acknowledge you are voluntarily sharing this information to initiate intake. It is not stored beyond what is needed to enter into the EMR.

Personal Information

First Name *

Last Name *

Date of Birth *

Phone *

Email *

Home Address

Street Address *

City *

State *

ZIP *

Care Type & Insurance

How would you like to be seen? *

Clinical Background

When did your symptoms begin and what triggered them?

Primary symptoms or concerns

Specialists or providers already seen

Anything else you'd like us to know?

We aim to respond within 2 business days. For urgent medical needs, contact your PCP or call 911.

Diagnostic Framework Consultation Inquiry

$1,500 flat-fee — available nationally, including states where Dr. Claunch is not licensed for ongoing care. Includes chart review, intake (~60 min), written Diagnostic Framework Summary, follow-up (~30 min), and optional provider phone discussion. Learn more →

Ongoing care is available at $250/30 min after the initial consultation for patients in licensed states.

Your Information

First Name *

Last Name *

Email *

Phone

State / Country of Residence *

Referring Provider (if any)

Clinical Background

Brief history — when did symptoms begin, what triggered them? *

Primary symptoms driving this request

Treatments already tried

What are you hoping to get from this consultation?

Preferred contact method

Best time to reach you

Response within 2 business days. Consultations are confirmed after a brief intake call.

Provider Inquiries

Select the option that fits your situation.

📋

Submit a Referral

Refer a patient for evaluation. A clinical summary is sent back after the initial assessment.

🤝

Become a Trusted Partner

Establish an ongoing collaboration — streamlined referral process and direct communication channel.

💬

General Provider Inquiry

Questions about the clinical framework, the PCP book, CME opportunities, or speaking requests.

Patient referral: The patient will receive a full sub-syndrome assessment. A written summary with primary and secondary treatment targets, sequencing recommendations, and medication suggestions is returned to you after each encounter.

Your Information (Referring Provider)

Your Name *

Practice / Institution *

Your Email *

Your Phone

Patient Information

Patient Name *

Patient Date of Birth

Patient Phone

Patient State of Residence *

Reason for referral / clinical summary *

Current medications relevant to this referral

The practice will contact the patient directly to schedule. You'll receive a clinical summary after the initial assessment.

Trusted partner providers receive a direct communication line, streamlined referral processing, and periodic clinical updates. This is for PCPs, neurologists, cardiologists, and other specialists who expect to refer multiple patients over time.

Your Name *

Specialty *

Practice / Institution *

Location (city, state)

Email *

Phone

Tell us about your patient population and what you're looking for

We'll be in touch within a few business days to set up an introductory call.

Name *

Specialty / Role

Email *

Topic

Message *

All provider inquiries are read. Response times vary by topic.

General Inquiry

Questions about the practice, the app, speaking engagements, media, or anything not covered above.

Your Information

Name *

Email *

Topic

Phone (optional)

Message *

We read all messages and aim to respond within a few business days.

Contact Dr. Claunch

Submit a Referral

Become a Trusted Partner

General Provider Inquiry