For support, call or text 704.850.6892

Fill Out Our Questionnaire!

Kindly fill out the below questionnaire to request a call from us!

Let's find out if we're a great fit for each other

Please fill out your information below and we'll be happy to see how we may best serve you!

First Name *

Last Name *

How old are you? *

Valid Email *

Cell Phone *

What are you the top health concerns that you would like us to help you overcome? *

Why is this goal important to you, and what do you think is stopping you from accomplishing it?

If you were to wake up tomorrow without this challenge, how would your life be different?*

Do you consider yourself coachable?

Yes

Do you have a supportive spouse, significant other, or friend to support your personal goals?

Yes

Who else have you worked with?

Functional Medicine Practitioner

Medical Doctor/Osteopathic Doctor

Medical Specialist

Naturopathic Doctor

Traditional Chinese Medicine

Nutritionist/Dietician

Personal Trainer

Chiropractor

Personal Development Coach

Other

If Other:

What functional lab testing have you done previously?

Functional Stool Testing

Organic Acids Testing

Adrenal/Cortisol Testing

Genetic or Genomic Testing

Hormone Testing

Food Sensitivity Testing

Heavy Metal Testing

None

Other

If Other:

Considering your past treatments, what would you like to improve or do differently moving forward?

Do you understand that most of the services on our practice are not covered by insurance? *

Yes

Are you willing to do what's necessary to reclaim your health? (This may include dietary modifications, functional lab testing, lifestyle and environmental modifications, etc) *

Yes

UTM Source

UTM Medium

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