Radiate Health: Hashimoto’s + Autoimmune Thyroid Program Interest Form
www.radiatehealth.net
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Form
Name
First Name
Last Name
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Email
example@example.com
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What is your date of birth?
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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How did you hear about me?
Facebook
Instagram
TikTok
Referral
I know you IRL friend!
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Have you been diagnosed with Hashimoto’s or another thyroid disorder?
Yes – Hashimoto’s
Yes – Hypothyroidism
No diagnosis yet, but I have symptoms
Other
Do you currently take any thyroid medication?
Yes – Levothyroxine
Yes – NP Thyroid / Armour / DTE
No, but interested
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Do you have any allergies? If so please list:
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Have you ever followed an Autoimmune Paleo (AIP) diet or elimination protocol?
Yes
No
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Are you currently experiencing any of the following?
Fatigue
Weight gain or resistance to weight loss
Brain fog or memory issues
Mood changes or anxiety
Bloating or GI issues
Cold hands/feet
Irregular menstrual cycles
Hair thinning or loss
Joint pain or muscle aches
Other
This 3-month program includes:✅ Functional medicine thyroid panels✅ Bioidentical hormone therapy (as needed)✅ Low Dose Naltrexone (LDN)✅ Gut and immune support✅ Anti-Inflammatory Autoimmune Paleo Protocol✅ Medical supervision and virtual appointments💰 Total Cost: $999 (includes labs, supplement recommendations, and provider support)Are you ready to get started with this 3-month comprehensive program for $999?
Sounds good, I'm ready!
Not right now, thank you!
Please verify that you are human
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Have you had routine labwork completed in the last 6 months?
Should be Empty: