First Name *

Last Name *

Email *

Phone *

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

Other

Of the above selected, which is the most important to you right now?

What previous treatments or methods have you tried in the past to accomplish your goals?

Have you ever worked with an integrative health and wellness professional before?

yes

If yes, please explain your experience

How important is it to you to accomplish your health 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 monthly?

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

Nutrition

Exercise

Energy

Libido

Stress Management

On a scale of 1-10 (10 being the most comfortable) how comfortable are you with needles and injections?.

Are there any specific questions you would like answered during your consultation?

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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