Wellness Consultation Request 🌿✨
Please complete this form to help us understand your goals before scheduling your consultation.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
Date
Sex
*
Female
Male
Non-binary
Prefer not to say
Email Address
*
example@example.com
Mobile Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
*
Phone call
Text message
Email
City and State
*
How did you hear about us?
*
Please Select
Friend or family referral
Healthcare provider
Social media
Internet search
Event or seminar
Other
Health Goals (select all that apply)
*
Weight loss
Longevity / healthy aging
Hormone optimization
Gut health
Fatigue / energy
Sleep
Cardiometabolic health
Other
Please describe any symptoms or concerns you would like to address.
*
Current medical conditions (please list)
Current medications (please list)
Current supplements (please list)
Allergies (please list)
Relevant past surgeries or major procedures
How often do you exercise?
Please Select
Daily
Several times a week
Once a week
Rarely
Never
Which best describes your typical diet?
Please Select
Standard American
Mediterranean
Vegetarian
Vegan
Paleo
Ketogenic
Other
Do you use alcohol?
No
Occasionally
Regularly
Do you use tobacco or nicotine products?
No
Occasionally
Regularly
Former user
What is your average sleep duration per night?
Please Select
Less than 5 hours
5-6 hours
6-7 hours
7-8 hours
More than 8 hours
Have you had any recent lab work?
Yes
No
Are you currently working with another physician for these issues?
Yes
No
Are you interested in in-person visits, telehealth, or either?
In-person visits
Telehealth
Either
What days or times generally work best for you to schedule a consultation?
I understand this is a request for consultation and not medical advice or emergency care.
*
I agree
I consent to be contacted about scheduling and acknowledge the privacy policy.
*
I consent
Submit Consultation Request
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