Application to Work with Dr. Laura

Work with Dr. Laura Patterson

Please complete all questions to apply for the Revitalize Hormone Balance program, a comprehensive "whole person" approach to hormone balance and wellness to help you feel your very best.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Phone Number*
Gender*
Date of Birth*

MonthDayYear
Date
What inspired you to apply to work with me on your health and hormone balance?*
What are your top 3 wellness goals?*
What are your biggest concerns/needs?*

Hormone balanceFatigueWeight lossStressSleepBrain fogLifestyle changesNutritionFitnessOther
How committed are you to making any changes that are needed to meet your wellness goals?*

Very committedSomewhat committedNot sure yet
Have you ever worked with the following:*

Health CoachNutritionistFunctional Medicine ProviderNone of these
How did you learn about this program?*

WebsiteSocial MediaEventPrimary Care ProviderFriend or other referralRecommended by Dr. Laura
Please share anything else you would like me to know:*
Choose Your Appointment Time*
Choose your appointment type:*

In Person at Hale Center Clinical PharmacyTelehealth (via Google Meet)Telephone
Your initial consultation will last 30-45 minutes. Prior to your appointment you will receive a link to complete a full hormone & health history.

During your appointment, we will do an in-depth review of your history and your concerns and goals. We will discuss next steps, including lab work and my initial recommendations to help you begin your journey.

Every in-person appointment also includes a complementary InBody Body Composition Analysis Test (a $20 value). If you don't live near us and want access to Body Composition data, I will send you a coupon code for a discount on a smaller home version of our professional InBody device.

Note: Consultations may be rescheduled with 24 hours notice. Missed appointments are not refundable.*

Initial Consultation

$75.00

Total

$0.00

Credit Card

Signature*

Clear
Signing Date*

MonthDayYear
Date
Should be Empty:

Work with Dr. Laura Patterson

Credit Card