Start Your Initial ConsultationFees May Apply Name* First Last-name Last Phone* Email* Address* Street Address * Address Line 2 * City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State * ZIP Code Date of Birth* GenderMaleFemale What is your height?* What is your weight?* Emergency Contact Name* First * Last Emergency Contact Phone* How did you hear about us?*Friend/Family MemberRadioInternet SearchSocial MediaOther Friend or family member name* What Radio Station?* What were you searching for on the internet?* What social media site/app did you see us on?* What other source did you find Your Wellness Center* Which service(s) will you be visiting our office for?*HormonesMedSpaWeight LossIV TherapyFood Sensitivity TestingSexual Medicine Medical History Do you have a history (current or past) of cancer?*YesNo Please answer: Type of cancer. Diagnosis date. Remission date.* Are you pregnantNoYesPossibleN/A Periods are*RegularIrregularNoneN/A HysterectomyFullPartialN/A Both Ovaries RemovedYes - BothYes - Only OneNo EndometriosisYesNo PolypsYesNo FibroidsYesNo Date of Last Mammogram** 0 of 150 max characters Date of Last Pap Smear* 0 of 150 max characters Medical Conditions/Symptoms*AnemiaADD/OCDAnxietyArthritisAsthmaBleeding disorderCancer(CHF)Congestive heart failureCOPDCoronary artery diseaseDepressionDiabetesCoronary artery diseaseDepressionDiabetesDiverticulitisEmphysemaGastritisGoutHeartburn/refluxHepatitisHiatal herniaHigh blood pressureHigh cholesterolHigh triglyceridesHIV/AIDSH‐pyloriIncontinenceIrregular heart beatIrritable BowelKidney diseaseKidney stonesLiver diseaseMigraines/HeadachesPolycystic Ovarian Syndrome (PCOS)Previous heart attackProstate problemsPulmonary EdemaRheumatic feverSleep apnea / snoringStent placedStomach ulcersStress urinary incontinenceStroke/TIA/seizureSubstance abuseThyroid problemsTuberculosisNONE OF THE ABOVE Do you have any of the following?*Protein-C DeficiencyProtein-S DeficinecyAnti-Thrombin III DeficiencyFactory 5 Liden DeficiencyG6PD DeficiencyNONE OF THE ABOVE Do any of your family members have a history of blood clots or a blood clotting disorder?YesNo Have you had a blood clot?YesNo Have you had any surgical procedures?YesNo Please list surgical procedures* Do you take any medications?YesNo Please list medications:* Do you take any supplements?YesNo Please list supplements:* Do you have any allergies or sensitivities?YesNo Please list allergies or sensitivities:* Such as foods, environment, medications, latex...etc Family History Do any of your family members have any medical conditions?YesNo Please list family medical history* Such as strokes, heart attacks, stents, diabetes, hypertension, high cholesterol, blood clots, etc. Hormone Information Hormone Imbalance Checklist*Aches and painsAnxietyApathyAutoimmune IllnessBone lossBrittle nailsChronic IllnessCold body temperatureDecreased libidoDecreased mental sharpnessDecreased muscle massDecreased staminaDecreased urine flowDecreased sexual satisfactionDepressionElevated cholesterolElevated triglyceridesErectile dysfunctionFibromyalgiaFoggy thinkingGeneral FatigueHair lossHeadachesHot flashesInability to lose weightIncreased urinary urgeInfertility problemsIrregular MenstruationIrritabilityLack of motivationMorning FatigueNight SweatsOily SkinPainful intercourseProstate problemsSleep disturbancesSusceptible to infectionsVaginal DrynessWeight gain in waistOther (list below)NONE OF THE ABOVE Preferred Pharmacy Preferred Pharmacy Name Preferred Pharmacy Address* Street Address * City * State / Province / Region ZIP / Postal Code Preferred Pharmacy Phone MedSpa Consultation Questions What service(s) are you interested in?*Free ConsultationLaser TreatmentInjectablesFacialsMicroneedlingChemical PeelDo you have other concerns? Select all that apply What skin condition(s) are you looking to treat?*AcneAnti-AgingMelasmaRosaceaSun DamageScarring/HyperpigmentationTone/TextureLines & WrinklesVolume LossDo you have other concerns? Select all that apply What is your skin type?*DryOilyCombinationSensitiveNormalNot Sure Select any that apply Weight Loss Progam Reasons for Weight Loss* Please list your top 5 reasons for weight loss Medical History Do you have a history (current or past) of cancer?*YesNo Please answer: Type of cancer. Diagnosis date. Remission date.* Are you pregnantNoYesPossibleN/A Periods are*RegularIrregularNoneN/A HysterectomyFullPartialN/A Both Ovaries RemovedYes - BothYes - Only OneNo EndometriosisYesNo PolypsYesNo FibroidsYesNo Date of Last Mammogram** 0 of 150 max characters Date of Last Pap Smear* 0 of 150 max characters Medical Conditions/Symptoms*AnemiaADD/OCDAnxietyArthritisAsthmaBleeding disorderCancer(CHF)Congestive heart failureCOPDCoronary artery diseaseDepressionDiabetesCoronary artery diseaseDepressionDiabetesDiverticulitisEmphysemaGastritisGoutHeartburn/refluxHepatitisHiatal herniaHigh blood pressureHigh cholesterolHigh triglyceridesHIV/AIDSH‐pyloriIncontinenceIrregular heart beatIrritable BowelKidney diseaseKidney stonesLiver diseaseMigraines/HeadachesPolycystic Ovarian Syndrome (PCOS)Previous heart attackProstate problemsPulmonary EdemaRheumatic feverSleep apnea / snoringStent placedStomach ulcersStress urinary incontinenceStroke/TIA/seizureSubstance abuseThyroid problemsTuberculosisNONE OF THE ABOVE Do you have any of the following?*Protein-C DeficiencyProtein-S DeficinecyAnti-Thrombin III DeficiencyFactory 5 Liden DeficiencyG6PD DeficiencyNONE OF THE ABOVE Do any of your family members have a history of blood clots or a blood clotting disorder?YesNo Have you had a blood clot?YesNo Have you had any surgical procedures?YesNo Please list surgical procedures* Do you take any medications?YesNo Please list medications:* Do you take any supplements?YesNo Please list supplements:* Do you have any allergies or sensitivities?YesNo Please list allergies or sensitivities:* Such as foods, environment, medications, latex...etc Family History Do any of your family members have any medical conditions?YesNo Please list family medical history* Such as strokes, heart attacks, stents, diabetes, hypertension, high cholesterol, blood clots, etc. Hormone Information Hormone Imbalance Checklist*Aches and painsAnxietyApathyAutoimmune IllnessBone lossBrittle nailsChronic IllnessCold body temperatureDecreased libidoDecreased mental sharpnessDecreased muscle massDecreased staminaDecreased urine flowDecreased sexual satisfactionDepressionElevated cholesterolElevated triglyceridesErectile dysfunctionFibromyalgiaFoggy thinkingGeneral FatigueHair lossHeadachesHot flashesInability to lose weightIncreased urinary urgeInfertility problemsIrregular MenstruationIrritabilityLack of motivationMorning FatigueNight SweatsOily SkinPainful intercourseProstate problemsSleep disturbancesSusceptible to infectionsVaginal DrynessWeight gain in waistOther (list below)NONE OF THE ABOVE Preferred Pharmacy Preferred Pharmacy Name Preferred Pharmacy Address* Street Address * City * State / Province / Region ZIP / Postal Code Preferred Pharmacy Phone What IV Therapy treatment are you interested in?*Get-Up-And-GoRecovery & PerformanceMyer's CocktailImmunityAlleviateInner BeautyNAD+ (250mg or 500mg)Vitamin C (Regular 5g)High-Dose Vitamin C (25g-75g)Amino Blend InjectionB12 InjectionMagnesium Injection If interested in High-Dose Vitamin C, bloodwork and a provider consultation are required prior to starting treatment. Medical History Do you have a history (current or past) of cancer?*YesNo Please answer: Type of cancer. Diagnosis date. Remission date.* Are you pregnantNoYesPossibleN/A Periods are*RegularIrregularNoneN/A HysterectomyFullPartialN/A Both Ovaries RemovedYes - BothYes - Only OneNo EndometriosisYesNo PolypsYesNo FibroidsYesNo Date of Last Mammogram** 0 of 150 max characters Date of Last Pap Smear* 0 of 150 max characters Medical Conditions/Symptoms - IV Therapy*AnemiaADD/OCDAnxietyArthritisAsthmaBleeding disorderCancer(CHF)Congestive heart failureCOPDCoronary artery diseaseDepressionDiabetesCoronary artery diseaseDepressionDiabetesDiverticulitisEmphysemaGastritisGoutHeartburn/refluxHepatitisHiatal herniaHigh blood pressureHigh cholesterolHigh triglyceridesHIV/AIDSH‐pyloriIncontinenceIrregular heart beatIrritable BowelKidney diseaseKidney stonesLiver diseaseMigraines/HeadachesPolycystic Ovarian Syndrome (PCOS)Previous heart attackProstate problemsPulmonary EdemaRheumatic feverSleep apnea / snoringStent placedStomach ulcersStress urinary incontinenceStroke/TIA/seizureSubstance abuseThyroid problemsTuberculosisNONE OF THE ABOVE Medical History - IV Therapy*(CHF)Congestive heart failureCoronary artery diseasePrevious heart attackPulmonary EdemaStent placedStroke/TIA/seizureNONE OF THE ABOVE Do you have any of the following?*Protein-C DeficiencyProtein-S DeficinecyAnti-Thrombin III DeficiencyFactory 5 Liden DeficiencyG6PD DeficiencyNONE OF THE ABOVE Do any of your family members have a history of blood clots or a blood clotting disorder?YesNo Have you had a blood clot?YesNo Have you had any surgical procedures?YesNo Please list surgical procedures* Do you take any medications?YesNo Please list medications:* Do you take any supplements?YesNo Please list supplements:* Do you have any allergies or sensitivities?YesNo Please list allergies or sensitivities:* Such as foods, environment, medications, latex...etc Family History Do any of your family members have any medical conditions?YesNo Please list family medical history* Such as strokes, heart attacks, stents, diabetes, hypertension, high cholesterol, blood clots, etc. Medical History Are you pregnantNoYesPossibleN/A Periods are*RegularIrregularNoneN/A HysterectomyFullPartialN/A Both Ovaries RemovedYes - BothYes - Only OneNo EndometriosisYesNo PolypsYesNo FibroidsYesNo Date of Last Mammogram** 0 of 150 max characters Date of Last Pap Smear* 0 of 150 max characters Medical Conditions/Symptoms*AnemiaADD/OCDAnxietyArthritisAsthmaBleeding disorderCancer(CHF)Congestive heart failureCOPDCoronary artery diseaseDepressionDiabetesCoronary artery diseaseDepressionDiabetesDiverticulitisEmphysemaGastritisGoutHeartburn/refluxHepatitisHiatal herniaHigh blood pressureHigh cholesterolHigh triglyceridesHIV/AIDSH‐pyloriIncontinenceIrregular heart beatIrritable BowelKidney diseaseKidney stonesLiver diseaseMigraines/HeadachesPolycystic Ovarian Syndrome (PCOS)Previous heart attackProstate problemsPulmonary EdemaRheumatic feverSleep apnea / snoringStent placedStomach ulcersStress urinary incontinenceStroke/TIA/seizureSubstance abuseThyroid problemsTuberculosisNONE OF THE ABOVE Do you take any medications?YesNo Please list medications:* Do you take any supplements?YesNo Please list supplements:* Do you have any allergies or sensitivities?YesNo Please list allergies or sensitivities:* Such as foods, environment, medications, latex...etc Medical History Do you have a history (current or past) of cancer?*YesNo Please answer: Type of cancer. Diagnosis date. Remission date.* Are you pregnantNoYesPossibleN/A Periods are*RegularIrregularNoneN/A HysterectomyFullPartialN/A Both Ovaries RemovedYes - BothYes - Only OneNo EndometriosisYesNo PolypsYesNo FibroidsYesNo Date of Last Mammogram** 0 of 150 max characters Date of Last Pap Smear* 0 of 150 max characters Medical Conditions/Symptoms*AnemiaADD/OCDAnxietyArthritisAsthmaBleeding disorderCancer(CHF)Congestive heart failureCOPDCoronary artery diseaseDepressionDiabetesCoronary artery diseaseDepressionDiabetesDiverticulitisEmphysemaGastritisGoutHeartburn/refluxHepatitisHiatal herniaHigh blood pressureHigh cholesterolHigh triglyceridesHIV/AIDSH‐pyloriIncontinenceIrregular heart beatIrritable BowelKidney diseaseKidney stonesLiver diseaseMigraines/HeadachesPolycystic Ovarian Syndrome (PCOS)Previous heart attackProstate problemsPulmonary EdemaRheumatic feverSleep apnea / snoringStent placedStomach ulcersStress urinary incontinenceStroke/TIA/seizureSubstance abuseThyroid problemsTuberculosisNONE OF THE ABOVE Do you have any of the following?*Protein-C DeficiencyProtein-S DeficinecyAnti-Thrombin III DeficiencyFactory 5 Liden DeficiencyG6PD DeficiencyNONE OF THE ABOVE Do any of your family members have a history of blood clots or a blood clotting disorder?YesNo Have you had a blood clot?YesNo Have you had any surgical procedures?YesNo Please list surgical procedures* Do you take any medications?YesNo Please list medications:* Do you take any supplements?YesNo Please list supplements:* Do you have any allergies or sensitivities?YesNo Please list allergies or sensitivities:* Such as foods, environment, medications, latex...etc Family History Do any of your family members have any medical conditions?YesNo Please list family medical history* Such as strokes, heart attacks, stents, diabetes, hypertension, high cholesterol, blood clots, etc. Hormone Information Hormone Imbalance Checklist*Aches and painsAnxietyApathyAutoimmune IllnessBone lossBrittle nailsChronic IllnessCold body temperatureDecreased libidoDecreased mental sharpnessDecreased muscle massDecreased staminaDecreased urine flowDecreased sexual satisfactionDepressionElevated cholesterolElevated triglyceridesErectile dysfunctionFibromyalgiaFoggy thinkingGeneral FatigueHair lossHeadachesHot flashesInability to lose weightIncreased urinary urgeInfertility problemsIrregular MenstruationIrritabilityLack of motivationMorning FatigueNight SweatsOily SkinPainful intercourseProstate problemsSleep disturbancesSusceptible to infectionsVaginal DrynessWeight gain in waistOther (list below)NONE OF THE ABOVE Preferred Pharmacy Preferred Pharmacy Name Preferred Pharmacy Address* Street Address * City * State / Province / Region ZIP / Postal Code Preferred Pharmacy Phone
