Request An Appointment | OptimalSelf MD

What Kind of Appointment Do You Need?

Wellness & Hormones

Plastic Surgery & Aesthetics

Health Coaching

IV Therapy

Massage Therapy

Other

Wellness

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First Name*

Last Name*

Email*

Phone*

SMS Consent

I would like to opt-in for SMS messaging.

Date of Birth*

Gender*

If others, please specify:

Occupation*

Zip Code*

How Did You Hear About Us?*

Please specify:

What Prompted You To Reach Out to Dr. Katherine Today?*

Please Identify Areas of Interest (Check all that Apply)*

Gut Health

Hormone / Thyroid Optimization

Hormone Pellets

Metabolic Repair / Medical Weight Loss

Hair Restoration

Sexual Health / Sexual Wellness Procedures

Age Management / Age Reversal Program

Health Optimization & Longevity

Other

List The Top 3 Health-Related Problems That Affect Your Daily Life*

On a scale of 1 to 10, how willing are you to make significant lifestyle and dietary changes to achieve your goals?*

If you don't make changes and get help now, where do you see yourself in the next 5 years?*

I understand that in order to maintain the freedom to practice medicine without restraint or coercion, OptimalSelf MD is NOT contracted with ANY health insurance company. Rates are clearly listed on the Consultation page of our website.*

Yes, I understand

Are You a Medicare Beneficiary?*

Yes

Please list any pertinent information or additional questions you may have. In order to better serve you, we also do a 15-minute pre-consultation phone call on all potential new patients, so you will have the opportunity to ask questions during that time.*

Thank you for taking the time to share this information with us. The next step is to book a 15 minute pre-consultation call with Dr. Katherine or Amy Martin, our NP*

During this call, Dr. Katherine or Amy will discuss your issues and goals in more detail. They will be able to provide you with a more specific idea of what we can do for you, the time it may take, the testing we would recommend, and the costs involved. This call requires a $100 fee paid in advance as well as the completion of our initial intake questionnaires. This fee would be applied to your first appointment or procedure should you choose to schedule. We are typically booking out a couple weeks in advance for the pre-consultation calls, and 4 to 6 weeks for new patient appointments. Would you like to book a call?

Yes, with Dr. Katherine

Yes, with Amy Martin, NP

Soonest Available

Not at this time

If not, please explain why:

When Is The Best Time to Contact You?

Are There Any Other Surgical/Aesthetic Services You Might Be Interested In? (Check all that Apply)*

Botox

Fillers

Sculptra

Facial PRP

Hydrafacial

Microneedling / Nano Needling

Other Aesthetic and Corrective Facials

Laser Hair Removal

Laser Skin Resurfacing - Skin Texture Solutions

Plastic Surgery

IV Therapy / Vitamin Injections

PRP/Exosomes / Stem Cells

Hair Restoration Solutions

Custom Chemical Peels

IPL - Skin pigmentation solutions

Photo Rejuvenation - Combo Skin Texture & Pigmentation Solutions

Ellacor - Skin Laxity and Aging Solutions

Integrative Nutrition Health Coaching

O-Shot / P-Shot for sexual wellness

Cellulite treatment

Sculptra/Radiesse

Hydrafacial/Keravive

Sexual wellness and aesthetics for men and women

Fertility Solutions

Red Light Therapies

Massage Therapy

PEMF Therapy

Infrared Sauna Therapy

Supplement Solutions

CO₂ Laser Skin Resurfacing

Other

N/A

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Massage Therapy

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First Name*

Last Name*

Email*

Phone*

SMS Opt-in

I would like to opt-in for SMS messaging.

Zip Code*

Length of time*

Message

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Plastic Surgery

"*" indicates required fields

First Name*

Last Name*

Email*

Phone*

SMS Opt-in

I would like to opt-in for SMS messaging.

Date of Birth*

Gender*

If others, please specify:

Occupation*

Zip Code*

Decision Stage*

Please Identify Any Plastic Surgery Areas of Interest (Check all that Apply)*

Upper Face / Eyebrows

Eyelids

Lower Face / Jowls

Neck

Breasts

Abdomen / Flanks

Thighs

Other

N/A

How Did You Hear About Us?*

Please specify:

Preferred Location For Surgery Consult

When Is The Best Time to Contact You?

Preferred Method of Contact*

If others, please specify:

Are There Any Other Non - Surgical/Aesthetic Services You Might Be Interested In? (Check all that Apply)*

Botox

Fillers

Sculptra

Hydrafacial

Microneedling / Nano Needling

Other Aesthetic and Corrective Facials

Laser Hair Removal

Laser Skin Resurfacing - Skin Texture Solutions

Cosmetic Laser Treatment

IV Therapy / Vitamin Injection

Gut Health

Hormone Replacement Therapy

Weight Loss

Sexual Wellness Procedures

Hair Restoration Solutions

Custom Chemical Peels

IPL - Skin pigmentation solutions

Photo Rejuvenation - Combo Skin Texture & Pigmentation Solutions

Ellacor - Skin Laxity and Aging Solutions

Integrative Nutrition Health Coaching

Cellulite treatment

Sculptra/Radiesse

Hydrafacial/Keravive

Sexual wellness and aesthetics for men and women

Fertility Solutions

Red Light Therapies

Massage Therapy

PEMF Therapy

Infrared Sauna Therapy

Supplement Solutions

CO₂ Laser Skin Resurfacing

Other

N/A

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We accept all major credit cards as well as Alpheon and Care Credit.

IV Therapy

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First Name*

Last Name*

Email*

Phone*

SMS Opt-in

I would like to opt-in for SMS messaging.

Zip Code*

Select a Procedure*

Message

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Other

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First Name*

Last Name*

Email*

Phone*

SMS Opt-in

I would like to opt-in for SMS messaging.

Zip Code*

What can we help you with?*

What is the best way to reach you? Feel free to leave a mobile phone number if you would like a text.

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Health Coaching

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Full Name(Required)

Email Address(Required)

Gender(Required)

Date of Birth(Required)

Phone Number(Required)

SMS Opt-in

I would like to opt-in for SMS messaging.

Zip Code(Required)

How Did You Hear About Us?(Required)

What are your health and wellness goals?(Required)

List Top 3 Issues You are Struggling with That a Health Coach Would Help With?(Required)

How Willing are You to Make Changes to Your Lifestyle?

On a scale of 1-5, 5 being most likely

Make dietary changes?(Required)

Modify or start an exercise program?(Required)

Perform recommend blood tests?(Required)

Begin a Nutrition Supplement Regimen(Required)

Maintain Weekly to Bi Weekly Contact with our Health Coach(Required)

What are you hoping to get out of Health Coaching?(Required)

I understand that in order to maintain the freedom to practice medicine without restraint or coercion, OptimalSelf MD is NOT contracted with ANY health insurance company. Pricing of services are listed on the Health Coaching page of our website.(Required)

Yes, I understand

Would you be interested in scheduling a complimentary call with our Health Coach?(Required)

Yes

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