Patient Enrollment and Update Form

Patient Enrollment / Update Form

Dr. Lauren Bramley BSc., MD., CCFPC, MSc. Endocrinology, Diabetes & Metabolism.
Name

First NameLast Name
Date of Birth

MonthDayYear
Sex
Contact Number:
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
Allergies to Medications, Supplements Other Allergens
Weight (pounds)
Height (inches)
Preferred Weight (If Different)
Taking any supplements, currently?

YesNo
If yes, please list here, ideally with brand and dose
Taking any prescribed medications ?

YesNo
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:

Hormonal ImbalanceThyroid DisorderMetabolic DisorderMitochondrial DisorderHeavy Metal or Mold ToxicityFoodAllergy or IntoleranceSIBO, Leaky Gut, CandidiasisInsulin ResistanceDiabetes or Pre-DiabetesCoronary Artery DiseaseHigh Blood PressureSleep Disorder
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 ?

23andmeSelf DecodeSellect SNPsOther
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.

YesNo
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.

YesNo
I would like to learn more about:

Peptide TherapyWeight ManagementBioidenltical Hormone TherapyAge ReversalTruage Trudiagnostic Biological Age TestingThe Better With Age ClubRegenera Activa Hair TreatmentHeavy Metal Testing and TreatmentMold Toxicity and TreatmentGenomicsImproving my AppearanceImproving my EnergyImproving my Cognitive FunctionSports PerformanceProdrome Sciences Plasmologen Testing & Treatment for Preventing Cognitive DeclineImproving my Mood, Joy In LivingImproving My NutritionAesthetic Medicine: Botox/Neuceiva Hyaluronic Acid FillersImproving my Love LifeOther
Please let us know your preferred time for a consultation on Pacific Time : example: early am, weekdays, weekends, evening etc..
Please list your Family Doctor, GP, Primary Care Physician Name and Location Here:
Please upload any previous lab results.

Cancelof
Please keep me informed of these upcoming Better With Age Club Events for 2022

London July 18, 2022Whistler, Aug 6 2022Miami August 15, 2022Vancouver, August 20, 2022Ikaria, Greece A BLUE ZONE September 24, 2022Victoria, Canada August 27, 2022Sydney November 15, 2022Melbourne November 22, 2022Las Vegas, December 12 2022I would like to hold a Corporate or Private Event featuring The Better With Age Club
Thank you for completing this form. Please choose a first or follow up zoom consultation with Dr Lauren Bramley form the calendly link below. You can also request an information call about The Better With Age Club.

https://calendly.com/lauren-donaldson-bramley
The Better With Age Club Membership. 1800 USD/Year or 175 USD/ Month

Includes:

Follow Up Truage Test Kit with Full Reports at Month 10

Day long in-person or virtual event with Dr Lauren Bramley

Virtual Truage Consultations x 2 with Dr Lauren Bramley

Club Pricing of 10% Discount on Therapeutics and Specialized Testing and Aesthetic Treatments

Does Not Include:

Initial Truage Test Kit 700 USD

Additional Consultations 250 USD

Prescriptions, Referrals, Therapeutics, Specialized Testing

Consultation Fees:

Better With Age Club Members:

Additional Consultation Fees 250 USD

Annual Prescription Fee Waived

Non Members

Consultation Fee 350 USD

Annual Prescription Fee 150 USD

Referral Fee For Radiology Investigations 100 USD

The Better With Age Club
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Patient Enrollment / Update Form