phone rotate icon 2

If viewing on a mobile device, flip sideways to display page properly.

Step 2 of 2: Please Complete This Quick Questionnaire To Reserve Your Phone Appointment With Dr. Hirsch

I'm very excited to connect with you to answer your questions and to evaluate if we would be the best practice to help you. Please fill out the information below so that we can make the most of our time together.


-Dr. Evan "The Fatigue Doc"


If you do not fill out this survey within 2 hours, your appointment will be cancelled and you will need to sign up again.


Contact Information
Insurance Information
Rate the following on a scale of 1 (not willing to do) to 5 (very willing to do)
Rate on a scale of 1 (not confident at all) to 5 (very confident)
Rate on a scale of 1 (not supportive) to 5 (very supportive)
Rate on a scale of 1 (not able) to 5 (very able)
Personal Notes (Optional)
If you have anything else about you you'd like us to know, please share that information here.
*Please do not use this space for private patient-practitioner information.*