Patient Enrollment and Update Form

Name

First NameLast Name

Date of Birth

MonthDayYear

Sex

Contact Number:

Format: (000) 000-0000.

E-mail

example@example.com

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Country

In case of emergency

Emergency Contact:

First NameLast Name

Relationship

Contact Number

Format: (000) 000-0000.

Allergies to Medications, Supplements Other Allergens

Weight (pounds)

Height (inches)

Preferred Weight (If Different)

Please list any Important Medical History: For example: diabetes, cancer, coronary heart disease , high blood pressure, ICU or hospital admission, drug reaction

Please list any known Important Medical History of your biological family: For example: diabetes, cancer, coronary heart disease, stroke, dementia

Taking any supplements, currently?

If yes, please list here, ideally with brand and dose

Taking any prescribed medications ?

If Yes Please List Here

Please list your top 10 concerns regarding your health and well being.

I suspect or have been told I may have:

Do you have a wearable health tracking device ? ex Oura Ring, Apple Watch, Garmin, Fitbit, Inmode, Dexcom ?

Have you had your Biological Age Tested ? ex Truage Trudiagnostic ? If so when and what was your result ?

Have you ever had Genetic Testing ? If so which one ?

Have You Had a Saliva, Urine or Blood Hormone Panel in the Past 12 months ? Please upload your result below or email to lauren.bramley@laurenbramleymd.com prior to your consultation.

Have you had other lab tests done in the past 12 months. Please upload your result below or email to lauren.bramley@laurenbramleymd.com prior to your consultation.

I would like to learn more about:

Please let us know your preferred time for a consultation on Pacific Time : example: early am, weekdays, weekends, evening etc..

Please List Your Pharmacy Preference Name , address and fax. If you use both a compound pharmacy and a regular pharmacy please list both.

Please list your Family Doctor, GP, Primary Care Physician Name and Location Here:

My current feeling about reversing my biological age is:

Please upload any previous lab results.

For Patient Residing Outside of the USA: Do you have a USA mailing address? Many specialized treatments and testing can be shipped to USA addresses only. We strongly recommend establishing a USA mailing address to ensure your access to these treatments. International Shipping Disclaimer (applicable, but not limited to, Canada, United Kingdom, Australia, European Union, Hong Kong ): The Better With Age Club LLC does not assume any responsibility for delays or delivery failures for any reason. Under no circumstances will we issue refunds for shipping charges or products that don't arrive, including customs interference. The customer assumes all risk for orders shipped outside the USA and its territories.

Thank you for completing this form. Please choose a first or follow up zoom consultation with Dr Lauren Bramley form the links below. You can also request an information call about The Better With Age Club.

To Book a Online Consultation For Existing Patients:
https://www.thebetterwithageclub.com/booking-calendar/virtual-consultation-for-non-members?utm_medium=page_links

To Book a Online Consultation For New Patients:
https://www.thebetterwithageclub.com/booking-calendar/new-patient-virtual-consultation?utm_medium=page_links

Patient Enrollment / Update Form