Amitabha Medical Clinic

Request Consultation

Amitabha Medical Clinic

Request Consultation

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Request Consultation

Thank you for your interest in therapeutic apheresis. This form helps our team understand why you are seeking care and whether therapeutic apheresis or other adjunctive therapies may be the right course of treatment for you.

Opening the Door to Greater Healing Potential

Every patient’s medical history, symptoms, and treatment goals are different. This brief questionnaire helps our clinical team better understand your needs and determine whether a consultation for therapeutic apheresis may be appropriate.


Please provide as much relevant information as possible. Recent laboratory results and medical records may also help support the review process.

Apheresis May Be Considered For

  • Chronic inflammatory and immune-mediated conditions
  • Cancer and integrative oncology care
  • Neurological and neuroinflammatory conditions
  • Cardiovascular and lipid-related concerns
  • Chronic kidney disease
  • Environmental illness and toxicant exposure
  • Complex chronic illness and hyperviscosity
Opening the Door to Greater Healing Potential

Submitting this questionnaire does not guarantee eligibility or treatment availability. Apheresis is recommended only after a new patient consultation and may require lab work.

If you have a referring provider, please contact our office directly. We welcome referrals by fax or directly through our Elation EMR platform.

Name
Preferred contact method
Areas of concern (check any that apply)
If you have active cancer or are currently receiving cancer-related care, are you currently working with an oncologist?
Do you currently take an ACE inhibitor (for example: lisinopril, enalapril, ramipril)?
Do you currently take blood-pressure medications, diuretics, or other blood thinners?
Have you ever experienced a reaction or complication during an IV infusion, blood transfusion, or other blood-related procedure?
If yes, please describe what happened.How would you describe your veins? (Apheresis requires appropriate vascular access.)
Do you have recent laboratory results that you can share?
If available, recent laboratory results and relevant medical records can help our clinical team review your case. These may include recent blood work, imaging reports, consultation notes, and your current medication and supplement list. You may send records to information@amitabhaclinic.com or via fax to (707) 542-5900. Note: Providing records is optional and does not establish a physician-patient relationship or guarantee that treatment will be recommended.
Are you currently pregnant, or trying to become pregnant?
Do you have known kidney disease or reduced kidney function?
Do you have a history of bleeding or clotting disorder, or unusually easy bruising?
Do you have a history of low blood pressure?
Are you under 18?
If you have been referred by your current medical provider for therapeutic apheresis, please have them provide a referral letter along with any recent records, relevant labs, medication list, and a short summary of diagnosis and goals. We accept referrals by email: information@amitabhaclinic.com or by fax: 707-542-5955.
Informed Consent