What Kind of Appointment Do You Need? Wellness Plastic Surgery IV Therapy Wellness Full Name* Email* Phone*Date of Birth* MM slash DD slash YYYY Gender*MaleFemaleOtherIf others, please specify: Occupation* Zip Code* ZIP Code How Did You Hear About Us?*InternetInstagramFacebookIn-Person EventWord of MouthPlease 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 Other If others, please specify: List The Top 3 Health-Related Problems That Affect Your Daily Life* In Order to Get the Results, How Willing are You to do the Following (On a scale of 1-5, with 1 being the lowest and 5 being the highest)Significantly modify what and how you eat?*54321Perform laboratory assessments that may include collection of blood, urine, stool, and saliva?*54321Take nutritional supplements each day?*54321Keep a detailed record of everything you eat for several days?*54321Modify your lifestyle (e.g. work demands, sleep habits, environment)?*54321Practice relaxation techniques daily?*54321Exercise at least 2 days a week or reduce the frequency of exercise?*54321Communicate with me frequently in order to achieve your goals?*54321Have periodic lab tests to access your progress?*54321I 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 No Please list any pertinent information or additional questions you may have:*We have many 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 us. The next step is to book a 15 minute consultation call with Dr. Katherine or Amy Martin, our NP.*During this call, Dr. Katherine will discuss your issues and goals in more detail. She will be able to provide you with a more specific idea of what she can do for you, the time it may take, the testing she 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 should you choose to schedule. She is typically booking out a couple weeks in advance for phone consultations as well as roughly 1-3 months for in-office new patient appointments. Would you like to book a call? Yes No Would You Be Interested in Scheduling a Complimentary Phone Consultation with Our Nurse Practitioner Amy Martin if This Meant You Could Potentially Get in Sooner? (dependent upon areas of interest)* Yes No When Is The Best Time to Contact You?Morning between 8 - 10 amMorning between 10 - 12 pmAfternoon between 1 - 3 pmAfternoon between 3 - 5 pmAre There Any Other Surgical/Aesthetic Services You Might Be Interested In? (Check all that Apply)* Botox Fillers Sculptra Facial PRP Hydrafacial Other Facials Microneedling/Nano Needling Laser Hair Removal Laser Skin Resurfacing Plastic Surgery IV Therapy/Vitamin Injections PRP/Exosomes/Stem Cells Other N/A If others, please specify: EmailThis field is for validation purposes and should be left unchanged. Plastic Surgery Full Name* Email* Phone*Date of Birth* MM slash DD slash YYYY Gender*MaleFemaleOtherIf others, please specify: Occupation* Zip Code* ZIP Code Decision Stage*Just Starting to ResearchEvaluating TreatmentsInterviewing DoctorsReady to Book a ProcedurePlease 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?*InternetInstagramFacebookIn-Person EventWord of MouthPlease specify: Preferred Location For Surgery ConsultThursday Afternoon Downtown GreenvilleWhen Is The Best Time to Contact You?Morning between 8 - 10 amMorning between 10 - 12 pmAfternoon between 1 - 3 pmAfternoon between 3 - 5 pmPreferred Method of Contact*EmailPhone CallTextIf 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 Facials Laser Hair Removal Laser Skin Resurfacing Cosmetic Laser Treatment IV Therapy/Vitamin Injection Gut Health Hormone Replacement Therapy Weight Loss Sexual Wellness Procedures Hair Restoration Other N/A If others, please specify: CommentsThis field is for validation purposes and should be left unchanged. We accept all major credit cards as well as Alpheon and Care Credit. IV Therapy First Name* Last Name* Email* Phone* Zip Code* Select a Procedure*Beauty IVBrainstorm IVFat Burning IVImmunity IVMigraine ReliefMyers CocktailMyers PushNADRecovery IVMessageEmailThis field is for validation purposes and should be left unchanged.
