Apply to Join Aviva Women's Health

Complete and submit this form to apply to become a patient of my practice.
Once received, I will review your application and my office will be in touch with a response within 10 business days.
If I feel we'll be able to support you in addressing your concerns and achieving your health goals, you'll receive the next steps for joining the practice and scheduling your appointment.

Name(Required)

First Last

Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Date of Birth(Required)

Gender

Please describe what health concerns you'd like Dr. Romm's help with.(Required)

Why are you seeking care at this time in particular? Has something recently changed for you?(Required)

What most interested you about this practice and working with Dr Romm?(Required)

How did you find out about Dr. Romm?(Required)

What are your expectations of this practice/Dr. Romm?(Required)

What do you see as your role in your health plan?(Required)

What have you tried before that worked? Didn't work?(Required)

How willing are you to make changes in your diet and lifestyle to reach your health goals on a scale of 0-5 with 0 being no motivation at all, 5 being “yes, ready, let’s go!” Check one.(Required)

Apply to Join Aviva Women’s Health

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