New Patient Consultation Intake
Thank you for considering East x West Med. We are a contemporary hormone health and longevity practice, blending functional, traditional, and progressive medicine for an elevated quality of life. This brief form helps us learn about you so we can make the most of your first conversation with our team. It should take about 2 minutes to complete - we look forward to supporting you! Once you're done, our Patient Success Director, Chelsea, will contact you and schedule your free initial consultation call.
We currently provide care in the following states NY, NJ, MA & FL. What State are you located in?
*
NY
NJ
MA
FL
Other
Our team includes Dr. Torrie Clontz, DNP, ANP, an experienced hormone and metabolic health clinician who shares the East x West Med approach to modern longevity care. Dr. Clontz is currently accepting a select number of new patients to ensure each one receives personalized, attentive care. Dr. Robbins’s membership panel is full at this time but is still accepting initial assessments. Which of the following options best fits your needs right now? (Don’t worry, we will confirm during your call!)
*
Work with Dr. Clontz for my full care, from assessment through ongoing management.
Complete my initial assessment with Dr. Robbins, then continue care with Dr. Clontz.
Complete my initial assessment with Dr. Robbins, then join the waitlist for Dr. Robbins’s panel.
What is your first and last name?
*
First Name
Last Name
What is the best email to contact you with?
*
example@example.com
What is your phone number?
*
Please enter a valid phone number.
Format: (000) 000-0000.
What is your preferred contact method?
*
Call
Text
Email
What are your preferred days and times for sessions?*
*
Weekday Mornings
Weekday Afternoons
Everyone’s health goals and budgets look different. What monthly range feels comfortable for ongoing care? This helps us match you with the right provider and plan. Flexible payment options are available, and we’ll walk you through everything on your consultation call. Membership does not include medications or labs.
*
Under $150/month
$150-$200/month
$200-$250/month
$250-$300/month
My goal is finding the best therapeutic fit, regardless of membership fee.
How did you hear about East x West Med?
*
Instagram
Facebook
TikTok
Google
Event
Podcast
Friend or Family
Returning Patient
Other
Is there anything you'd like our team to know before your initial consultation?
*
Submit
Should be Empty: