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New Patient Intake
Welcome to The Be Well Family!
24
Questions
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1
WHAT TO EXPECT AS A PATIENT OF BODY LABS M.D.
The process is quick and easy to start your transformation
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2
WHY CHOOSE BODY LABS M.D.
How is our Hormone and Weight loss Clinic Different?
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3
BE WELL BODY LABS FAQs: Select each box you would like detailed info for.
Who we are, what we do, who we serve
WHO IS BODY LABS?
WHAT DO WE OFFER?
HOW DOES IT WORK?
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4
Name
*
This field is required.
YOUR INFORMATION IS PROTECTED AND FOR OFFICE USE ONLY
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5
Phone Number
*
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YOUR INFORMATION IS PROTECTED AND FOR OFFICE USE ONLY
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6
Email
example@example.com
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7
What Telemedicine services interest you?
You may choose multiple options.
Men's Hormones (TRT)
Medical Weight Loss
Women's Hormones (BHRT)
Peptide Body Optimization
Prescription Skin Care
In Depth Lab Testing
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8
Do you consent to communication from our Care Coordinators?
YOUR INFORMATION IS PROTECTED AND FOR OFFICE USE ONLY
Yes, use any form of contact
Calls Only
Email Only
Texts Only
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9
REAL QUICK! Got a question? Send us a message on FACEBOOK below
Get a response within minutes or text us at 580.448.0001
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10
Choose below to continue this intake form if you are ready to get started, or if you would like our team to contact you for an informational call.
The rest of the form is fast and speeds up the process. We often have same day availability.
I am READY TO START, I'll continue this short form now.
I just want more information about your clinic/pricing/protocol before continuing this form. Please contact me.
I will be in touch when I am ready. You may add me to your email list for non- spam updates.
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11
Date of Birth
*
This field is required.
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Month
Day
Year
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12
Gender
*
This field is required.
Please Select
Male
Female
Transitioning
Prefer not to say
Please Select
Please Select
Male
Female
Transitioning
Prefer not to say
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13
Address
MAILING ADDRESS
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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
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
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14
What are your mind/body goals and an ideal time frame to reach them?
You may skip for now if preferred
Yes? Explain briefly
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15
Which symptoms would you like to improve?
You may skip for now if preferred
Overall drive
Symptoms of depression
Difficulty sleeping
Hot flashes
Loss of concentration, sociability, and activity
Loss of interest in sex
Decreased desire and ability to exercise
Decreased energy and endurance
Decreased sense of well-being
Decreasing memory
Decreasing muscle strength
Sagging, loose or thin skin
Sore Muscles, joint pain(s)
Weight loss - Unexplained
Reduced erectile function
Pale Skin, We can tan you with Melanotan Peptide!
Feeling very tired all the time (fatigue)
Obesity
Please Select
Overall drive
Symptoms of depression
Difficulty sleeping
Hot flashes
Loss of concentration, sociability, and activity
Loss of interest in sex
Decreased desire and ability to exercise
Decreased energy and endurance
Decreased sense of well-being
Decreasing memory
Decreasing muscle strength
Sagging, loose or thin skin
Sore Muscles, joint pain(s)
Weight loss - Unexplained
Reduced erectile function
Pale Skin, We can tan you with Melanotan Peptide!
Feeling very tired all the time (fatigue)
Obesity
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16
Are you interested in peptides (BCAA's) for any of the life improving therapies listed below?
Peptides are safe, effective therapies that improve all aspects of physical and cognitive health and quality of life
Growth Hormone Stimulator
Hormone Enhancement
Cardiovascular health
Metabolic boost
Age Rewind
Weightloss Peptides
Complete Pro Performance Peptide Blend
Please Select
Growth Hormone Stimulator
Hormone Enhancement
Cardiovascular health
Metabolic boost
Age Rewind
Weightloss Peptides
Complete Pro Performance Peptide Blend
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17
Would you like to recommend anyone for a free consultation? We offer discounts for both of you.
This can be a partner, friend or family member as well.
YES
NO
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18
Have you had your labs done in the past 3 months?
This is only needed for hormone prescribing
Yes, I can send in my lab results
No, but I am interested in checking my levels
Only here for the weightloss with no labs
Curious about pricing and type of testing offered
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19
What form of lab testing do you prefer?
We mail at home saliva tests or order lab blood draws - Statewide.
IHC, Quest, or Lab Corp.
Concierge Blood draw from home/work? ($50 nurse travel fee state wide.) $200+
Blood draw as a walk in to Quest or Labcorp $150+
Saliva testing kit shipped to you? $100
Please Select
Concierge Blood draw from home/work? ($50 nurse travel fee state wide.) $200+
Blood draw as a walk in to Quest or Labcorp $150+
Saliva testing kit shipped to you? $100
Hormone levels are all we require. As an added benefit, we have full lab testing capabilities at clinic cost available for all bodily systems.
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20
Choose your preferred form of payment
Invoiced Cash/Self pay (discounted clinic pricing)
Monthly Auto PAy
FSA/HSA account
CARE credit
Affirm or Financing
Please Select
Invoiced Cash/Self pay (discounted clinic pricing)
Monthly Auto PAy
FSA/HSA account
CARE credit
Affirm or Financing
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21
Would you like to apply for low income pricing?
Explain your situation briefly
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22
Do you consent to telehealth treatment and virtual services?
*
This field is required.
If no, please exit the form
Yes
No
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23
Do you have any known allergies? If yes, then please specify below.
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24
Do you have any known allergies?
YES
NO
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25
List your allergies below
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26
Are you currently taking any medication?
YES
NO
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27
List your medications below.
Medications I am taking
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28
Are you currently taking medications? If yes, then please list the medications and the reasons
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29
Do you have any communicable diseases, cardiovascular problems, diabetes, asthma etc.?
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30
Do you want to take advantage of our money back guarantee for weightloss? We will send a separate agreement form.
Conditions apply such as video administration and weekly weigh ins.
YES
NO
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31
Please submit photo of Government issued ID card below
USED FOR INTAKE/PRESCRIBING AND KEPT PRIVATE
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32
Insurance Card (for Labs only)
If you have insurance please upload a picture of your card- lab orders only
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Max. file size
: 10.6MB
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33
Patient Signature
*
This field is required.
Clear
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34
Date Signed
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Month
Day
Year
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