Thank you for your interest in the Bateman Horne Center (BHC)

Thank you for your interest in the Bateman Horne Center (BHC)
Please note that while we are working to build capacity, we still have work to do before we can serve every patient who fills out an inquiry form. We know there is a high demand for clinicians who can treat complex illnesses, and our vision is that someday we will be able to serve every individual who needs and deserves quality care.

Your inquiry is valuable in helping us determine need and strategize our growth. However, please be aware that it may take time before we are able to respond. Thank you for your patience and understanding as we grow and expand our impact.

By completing this form, you are:
- Giving BHC permission to reach out if clinic capacity increases in the future.
- Indicating your interest in being contacted if you may qualify for research studies conducted by and with BHC.
Please note: Completing this form does not constitute as an agreement to be seen at BHC and does not create a patient–provider relationship. BHC is a nonprofit organization with limited resources, and your submission helps us understand community needs and connect individuals to opportunities as they arise.

In the meantime, we encourage you to review and share our Clinical Care Guide, and other educational resources with your current healthcare provider. These tools are designed to support care management and link you to both local and global resources.

Also, please be sure to subscribe to our email list to receive communication fabout new and upcoming educational resources, webinars, and community events.

Please Provide your contact details
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Contact Method
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState

Zip Code

Suspected or Known Diagnoses
ME/CFS (Myalgic encephalomyelitis/Chronic Fatigue Syndrome)
Symptom Onset
Do you regularly see a provider for treatment for your symptoms?
Name of treating physician (optional)
Long COVID
Symptom Onset
Do you regularly see a provider for treatment for your symptoms?
Name of treating physician (optional)
Fibromyalgia
Symptom Onset
Do you regularly see a provider for treatment for your symptoms?
Name of treating physician (optional)
POTS (Postural Orthostatic Tachycardia Syndrome)
Symptom Onset
Do you regularly see a provider for treatment for your symptoms?
Name of treating physician (optional)
Mast Cell Activation Syndrome
Symptom Onset
Do you regularly see a provider for treatment for your symptoms?
Name of treating physician (optional)
Ehlers Danlos Syndrome
Symptom Onset
Do you regularly see a provider for treatment for your symptoms?
Name of treating physician (optional)
Sjogren's Syndrome
Symptom Onset
Do you regularly see a provider for treatment for your symptoms?
Name of treating physician (optional)
Food Allergies, Sensitivities & GI Conditions
Symptom Onset
Do you regularly see a provider for treatment for your symptoms?
Name of treating physician (optional)
Hereditary Angiodema (HAE)
Symptom Onset
Do you regularly see a provider for treatment for your symptoms?
Name of treating physician (optional)
Asthma, Eczema & Hives Allergies
Symptom Onset
Do you regularly see a provider for treatment for your symptoms?
Name of treating physician (optional)
Please briefly list your top 3-5 health concerns.
Do you have a provider willing to work with your illness?
Providers Name

First NameLast Name
Providers Address

Street Address

Street Address Line 2

CityState

Zip Code

Availability & Accessibility

Rows	Yes	No
Are you able to attend appointments in Salt Lake City, Utah?
Would you prefer telehealth (If available in your State)?
Are you interested in participating in clinical research and able to travel to Salt Lake City, Utah?

Consent & Acknowledment
I understand that Bateman Horne Center is currently unable to provide an estimated timeline for new patient appointments.
I understand that submitting this interest form does not create a patient-provider relationship, does not guarantee future medical care, and does not ensure participation in any research study. Completion of this form places no obligation on BHC to provide services or opportunities, nor does it obligate me to participate in them.
I give permission for Bateman Horne Center to contact me when interest-aligned opportunities become available.
I understand that Bateman Horne Center operates from an all-cash model and does not accept health insurance.
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