New Patient Request Form
Welcome, this page is for new patients only. If you are already a patient with Optimal Vitality Concierge, please log into the portal. Please Note: We can only provide services to patients who are currently in the state of Illinois.
Personal Information:
Gender of Legal Record:*
Contact Information
Address
Please select a Provider:
Brandi Boan
PsyD, ASPPB, MSCP
Your Information is confidential. However, if you are uncomfortable fully describing your reasons for seeking services, please provide enough information so our staff can match you with the appropriate provider.
Submit
Cancel

New Patient Request Form

Welcome, this page is for new patients only. If you are already a patient with Optimal Vitality Concierge, please log into the portal. Please Note: We can only provide services to patients who are currently in the state of Illinois.
Personal Information
Contact Information
Phone

Address

Please Select a Provider:
Please explain the reason you are seeking help at this time:
Submit
Cancel
Clinic Address
200 S. Frontage Rd Suite 324
Burr Ridge, 60527-6953
Billing Address
200 S. Frontage Rd Suite 324
Burr Ridge, IL 60527-6953
Clinic Phone No.
(630) 360-1173

Billing Phone No.
Business Hours
By Appointment Only