Functional Lab Support Consultation Request Form

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E-mail* This field is required.
example@example.com
2
Full Name* This field is required.
First Name
Last Name
Post-nominal letters
3
Birth Date* This field is required.
Date
Month
Day
Year
4
Biological Sex
Female
Male
Other
5
Address* This field is required.**Please note that we are only able to assist in the retail ordering of tests for clients within the United States of America. Clients in the states of NY, NJ, RI, and CA may not be able to access certain forms of testing. Please reach out for more information or questions.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Is this session being booked for your labs or for a client's labs?* This field is required.Note: we ONLY work with practitioners and are not available to work with your client directly
I am looking for assistance with personal labs
I am looking for assistance with a client's labs
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Which functional test(s) are you looking for support with?* This field is required.Note: we do not offer support for tests outside of the options listed below
Blood Chemistry
DUTCH Complete
Serum Hormones
DUTCH Plus
GI Map
DUTCH Cycle Mapping
MRT Food Sensitivity
I'm not sure
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Do you need assistance with a retail order of a functional test?* This field is required.
Yes, I need assistance with purchasing a test (30-min onboarding upgrade will be added)
No, I have already taken my test and have my results ready to share
Other
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If you selected "No, I have already taken my test and have my results to share" to the previous question, please select which test(s) you have availableNote: this session includes the review of (one) test. Additional tests may be subject to an additional fee for review.
Blood Chemistry
DUTCH Cycle Mapping
DUTCH Plus
GI Map
DUTCH Complete
MRT Food Sensitivity
Other
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Please list all DATES and TIMES each test was takenSkip to the next question if not applicable
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Please share a little about your situation, goals, and desires for functional testing* This field is required.If this consultation is to review a client's case, please share about the client in this section
12
If you are female, do you currently experience ovulation and menstruation?If this consultation is to review a client's case, please share about the client in this section
Yes, I ovulate and menstruate regularly
Yes, but my ovulation and menstruation are irregular
No, I do not ovulate or menstruate
Other
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Do any of these situations apply to you? (if not, skip to next question)If this consultation is to review a client's case, please share about the client in this section
I am post-menopausal
I have not menstruated for longer than 6 months and am NOT post-menopausal
I have had a total hysterectomy (ovaries + uterus removed)
I have had a partial hysterectomy (uterus removed, ovaries remain)
I am on hormone replacement therapy (HRT or BHRT)
I am on hormonal birth control
I have recently come off hormonal birth control (within last 3 months)
I am currently pregnant
I am within 6 months of postpartum
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On what date was your last menstrual period?If this consultation is to review a client's case, please share about the client in this section
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On average, how long are your menstrual cycles? (from period to period)If this consultation is to review a client's case, please share about the client in this section
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What do you hope to achieve by the end of our consultation together?* This field is required.
17
Is there anything else you'd like to share?
Huge
Large
Normal
Small
Ok
Ok
18
How did you find out about us? Were you referred by anyone? If so, who? (so we can thank them!)
19
Is there an advanced practitioner you'd prefer to work with?* This field is required.Depending on the support you are seeking, you may be paired with the mentor that is best suited to support you.
Ashe Milkovic
Sarah Bouse
No Preference
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How soon are you wanting to get started?* This field is required.
This week
This month
Next month
Within the next 3 months
I am just inquiring
21
I understand that a minimum fee of $247 will be due at the time of scheduling the session, and if I need assistance with ordering or taking a test, a $50 onboarding session fee will also be applied.* This field is required.
Yes, I understand & agree
22
I understand that submitting this intake form does not establish a client relationship status and does not automatically reserve me a consultation.* This field is required.
Yes, I understand & agree
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