Full Name
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Phone
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Email
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Instagram Handle (for updates and exclusive events)
How did you hear about us?
What are you hoping to accomplish with a professional lab review and consultation?
General wellness checkup
Improve energy, mood and mental acuity
Achieve fitness / weight gain or weight loss goals
Prevent or correct chronic illness
Enhance sexual health
Balance hormone health
Learn more about longevity and regenerative options
Discuss the latest biohacking methods
Other
Of the above, what is most important to you right now?
What previous treatments or methods have you tried in the past to accomplish your goals?
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Have you ever worked with an integrative health and wellness professional before?
Yes
No
If Yes, please explain your experience.
How important is it to you to accomplish your goals at this time in your life?
Very Important
Fairly Important
Important
Slightly Important
Not at all Important
How much are you currently investing into your health?
Between gym memberships, supplements, nutrition etc
If you were grading yourself A through F how would you grade yourself in these areas in the last few months? (Standard academic grading scale; A+ being the best, F being failing)
Sleep
A
B
C
D
F
Nutrition
A
B
C
D
F
Exercise
A
B
C
D
F
Energy
A
B
C
D
F
Libido
A
B
C
D
F
Stress Management
A
B
C
D
F
On a scale of 1-10 (10 being the most comfortable) How comfortable are you with needles and injections?
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Are there any specific questions you would like answered in your Consultation?
What other services would you be interested in learning more about?
What other services would you be interested in learning more about?
Is there anything else you would like to share before your Initial Consultation with our team?
We are proud to offer highly studied approaches to functional medicine many of which are not covered or reimbursed by traditional insurance. We offer multiple levels of affordable programs with financing available and we take HSA/FSA forms of payments. At this time we are not able to bill through insurance companies.
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