864-663-1266

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Plastic Surgery
Functional Medicine & Wellness
Hormones & Sexual Health
- Hormone Replacement Therapy
- Sexual Health
  - Sexual Wellness for Men
    - StaminaWave for Men
    - The Optimal Shot
  - Sexual Wellness for Women
Medical Aesthetics
IV Nutrient Therapy

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Request An Appointment

What Kind of Appointment Do You Need?

Plastic Surgery

Wellness

Full Name*

Email*

Phone*

Date of Birth*

MM slash DD slash YYYY

Gender*

If others, please specify:

Occupation*

Zip Code*

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

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?*

Perform laboratory assessments that may include collection of blood, urine, stool, and saliva?*

Take nutritional supplements each day?*

Keep a detailed record of everything you eat for several days?*

Modify your lifestyle (e.g. work demands, sleep habits, environment)?*

Practice relaxation techniques daily?*

Exercise at least 2 days a week or reduce the frequency of exercise?*

Communicate with me frequently in order to achieve your goals?*

Have periodic lab tests to access your progress?*

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

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?

Are 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:

Comments

This 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*

If others, please specify:

Occupation*

Zip Code*

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

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:

Phone

This 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*

Message

Comments

This field is for validation purposes and should be left unchanged.

OptimalSelf MD

Call Us Today! 864-663-1266

2 Beautiful Locations:

25 S Laurens St
Greenville, SC 29601

2801 Woodruff Rd. Suite 202
Simpsonville, SC 29681

fax: office@optimalselfmd.com

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Wellness, Aesthetics & Plastic Surgery Practice in Greenville, SC

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