Intake Form - Ageless Blonde
Please fill out the form below so we can serve you best.
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What are your top 3 health concerns or goals right now (e.g., longevity, weight management, energy, hormones, anti-aging, aesthetics, performance)?
On a scale of 1–10, how committed are you to making lifestyle changes (nutrition, exercise, sleep, mindset) to reach your goals?
Have you worked with a functional medicine, concierge doctor, or health coach before?
Yes
No
Are you prepared to invest in a concierge wellness program (including labs, peptides, supplements, and visits) that may range from $300 - $1000? *We are cash pay and do not currently accept any insurance.
When it comes to your health, do you prefer to be:
Guided with a structured plan and accountability
Given recommendations but left to self-manage
Only interested in prescriptions/quick fixes
How would you describe your current lifestyle (stress level, diet, exercise, alcohol, sleep)?
Have you been diagnosed with any chronic conditions (e.g., diabetes, autoimmune, heart disease) or had recent hospitalizations?
Are you interested in exploring therapies like peptides, IV infusions, biohacking tools, or longevity-based protocols?
Do you have a supportive environment (family, friends, workplace) that will encourage you in making health changes?
If we work together, what would success look like for you in 6–12 months?
Signature
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