Dr. Lori's R3AL3 for Men's Lifegevity REV

Are you ready to Age YOUR Way?

Let's get started.
Dr. Lori's R3AL3 Integrative Medicine Program

Pease fill out form and CLICK SUBMIT at the end. You will receive a notice that your form has been submitted. On the "Thank You" confirmation there is a link to schedule your complimentary consultation. Please allow 24-48 hours for a representative from our office to confirm your complimentary consultation appointment and get all your paperwork started.

**(BHRT) = Bioidentical Hormone Replacement Therapy)
Date

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name

First NameLast Name
Birthdate

MonthDayYear
Date
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status
Referral Source: Please let us know how you found about us!
Please tell us who referred you. (Name of Referral Source)
Please state your height, weight & occupation.
Name of Primary Care Physician, Address & Phone Number
Pharmacy Name
Pharmacy Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name of Insurance Provider
Insurance Type (ie. HMO, PPO)
Allergies: Please check all that apply

Other
If applicable, please list your specific allergy and type of reaction:
Please list current prescription medications and nutritional supplments (please have them available during your virtual consultation.) Please note: NAME, STRENGTH, DATE STARTED & HOW OFTEN PER DAY
Over the counter (OTC) issues. Please check all products that you use at least once or more per month.

Other
Do you use any of the following (check if yes):
Hormones previously or currently taking (List NAME, DATE START, DATE STOPPED, REASON)
Do you have any of the following medical conditions? Check all that apply.

Other
Do you have any of the following symptoms? Check all that apply.
Please expand on any symptoms checked above and list any other symptoms that you are experiencing not list above. THIS WILL HELP OUR PROVIDER CATER YOUR INTAKE CALL & NEXT STEPS.
Please list any questions that you may have.
If you are interested in Dr. Lori's R3AL3 Weight Management OR GLP Program IN ADDITION TO OVERALL WELLNESS, please complete this section. IF NOT, SKIP TO BOTTOM OF THE QUESTIONAIRRE.
Do you have any history of the following? Check all that apply:
Have you ever used other diet medications? If yes, did you have any problems? Please describe your experience below:
How long have you struggled with your weight?
Do you have any known or presumed food allergies?
Please upload a copy of the front and back of your insurance card.

Cancelof
Upload RECENT or RELEVANT LABS from the last 12 months

Cancelof
By typing your name and date below, we will accept this as your signature and acknowledge that you have read and reviewed this questionnaire.

Full Name Date
PLEASE NOTE BY TYPING YOUR NAME AND DATE BELOW, YOU ACKNOWLEDGE THAT DR. LORI IS NOT FINANCIALLY RESPONSIBLE FOR ANY LABS THAT ARE NOT COVERED BY YOUR INSURANCE COMPANY. WE DO OUR BEST TO GIVE YOU THE MOST ECONOMICAL OPTION POSSIBLE AND HAVE NEGOTIATED PRICES FOR SELF PAY OPTIONS WITH SOME LABS IF REQUIRED. IT IS YOUR RESPONSIBILITY TO CALL YOUR INSURANCE REGARDING LABORATORY CHARGES IN AND OUT OF NETWORK OPTIONS & DEDUCTIBLE INFORMATION.

Full Name Date
After you submit your form, you will receive a "Thank you for your submission" email. This email will have a link to schedule your complimentary consultation WITH OUR MEDICAL PATIENT COORDINATOR. Please schedule your "Consultation- Intake Appointment" when you receive your 'Thank you" email.
Should be Empty:

Are you ready to Age YOUR Way?

If you are interested in Dr. Lori's R3AL3 Weight Management OR GLP Program IN ADDITION TO OVERALL WELLNESS, please complete this section. IF NOT, SKIP TO BOTTOM OF THE QUESTIONAIRRE.

After you submit your form, you will receive a "Thank you for your submission" email. This email will have a link to schedule your complimentary consultation WITH OUR MEDICAL PATIENT COORDINATOR. Please schedule your "Consultation- Intake Appointment" when you receive your 'Thank you" email.