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How did you hear about my practice? If you were referred by someone, list their name here so I can credit them
What prompted you to reach out to me today?
*
Which statement describes you the best?
*
I have a specific health issue and I'm looking for a Functional Medicine approach
I'm generally well, would like to be even better, and I'm looking for a Health Optimization approach
I am interested in bio-identical hormone therapy and/or thyroid management
I am interested in sexual wellness procedures
I need help with gut health
I am interested in medical weight loss
List the top 3 health-related problems that affect your daily life
*
In order to get the result you desire, how willing are you to do the following
*
Very
Somewhat
Hesitant
Not at all
How confident are you that you will be able to stick to your plan?
*
Very
Somewhat
Hesitant
Not at all
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?
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Yes
No
Please list any pertinent information or additional questions you may have:
We have more patients apply than we can accommodate at this time. For this reason, we do a pre-appointment consultation call. Why do you think you would be a good fit for our practice?
Thank you for taking the time to share this information with me. The next step is to book a 15-minute consultation call.
*
During this call, we can discuss your issues and goals in more detail, and I can provide you with a more specific idea of what I can do for you, the time it may take, the testing I would recommend, and the costs involved. This call requires a $100 fee paid in advance, and filling out our initial intake questionnaires. This fee will be applied to your first appointment should you decide to schedule. Would you like to book a call?
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