Intake Form

1
On a scale of 1–5 (1 being excellent, 5 being terrible), how is your current diet?
1. Excellent – High protein, low carbohydrates, minimal processed foods
2. Good – Mostly whole foods with occasional processed foods
3. Average – Mix of healthy foods and processed foods
4. Not great – Frequent processed foods and inconsistent nutrition habits
5. Terrible – Processed foods / fast food most days
Other
2
On a scale of 1–5 (1 being excellent, 5 being terrible), how is your current exercise regimen?
1. Excellent – Resistance/weight training 4–5 days per week with daily cardio or activity
2. Good – Resistance training 2–3 days per week and cardio most days
3. Average – Exercise 1–2 days per week or occasional activity
4. Not great – Rarely exercise or only light activity
5. Do not exercise
Other
3
Pricing

HRT/TRT medical consult: $249 (required for all orders except supplements and counseling)

Comprehensive blood work: $199 (required for HRT/TRT or recent blood work of your own)

Treatments/Prescriptions: Varies depending on qualification

Nutritional counseling: $125-$145 per session, depending on volume

Supplements: Pricing available on our website
4
Lead Source
5
Wellness Specialist
6
Let’s start with your full legal name:* This field is required.Enter your full legal name so your records are accurate and secure.
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7
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8
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9
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10
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11
What is your gender?* This field is required.This helps providers personalize your treatment plan with precision.
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12
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13
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Pricing