Full Name
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Email
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Phone
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Date of birth
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Do you live in Georgia or South Carolina?
*
Yes - Georgia
Yes - South Carolina
No
What is your zipcode?
Are you open to meet via tele health?
Yes
No
How did you hear about us?
Google Search
Referred by Provider
Referred by Family or Friend
Facebook
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Appointment Preference
First Available ( Usually same week, possibly same day)
Weekday Mornings
Weekday Afternoons
Friday Evenings 5-8PM (limited appointments)
Saturdays (limited appointments once monthly)
Telehealth
Reason(s) for Visit
Medical Weight Loss
Women's Bio-Identical Hormone Replacement Therapy Women's Bio-Identical Hormone Replacement Therapy
Men's Low Testosterone Treatment
Thyroid Disorders
Gut Health & Digestion
Food Sensitivity Testing
Cortisol & Stress Response
Toxins & Heavy Metal Exposure
Advanced Cardiac Panel & Cholesterol Testing
Genetic Testing, MTHFR
Autoimmune Conditions
What are your BIGGEST obstacles when achieving your health goals?
Financial
Time - Too Busy
Lack of Knowledge
Too Tired
Current medical treatment is not working well
Other
What are you looking for in a healthcare provider? (choose all that apply)
Listens to me
Looks at the big picture (holistic approach)
Collaborates with me to help me make the best health decisions for my circumstances
Looks for the root causes of my medical problems instead of just addressing my symptoms
Do you have any questions that you want to be sure we address when we speak?
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