SHOPCART
SHOPCART

Your Appointment is Confirmed

Congratulations on getting started and scheduling your appointment! In order to make sure we have the correct information for your medical record, please complete the short intake questionnaire below. All questions need to be answered (can’t skip anything), and it should only take a minute or two to complete. Thank you in advance for submitting this form. Please check your email for appointment confirmation notices and additional information regarding your labs.

APPTS: Main Health and Wellness Questionnaire
Address
Address
Street Address
Address Line 2
City
State / Province
ZIP / Postal Code
Referral Code
Were you referred by an existing patient?
First
Last

Medical History

Do you have or have you ever had any of following? (check all that apply)
Are you currently on birth control?

Wellness

Feeling at your peak/great sense of well-being:
Currently on HRT therapy:
Joint/back pain:
Trouble sleeping at times:
Irritability/Nervousness or Anxiety:
Decrease in muscular strength:
Decline in libido or ability to perform at times:
Hot flashes/sweating:
Vaginal dryness:

Activity Level

My work is demanding physically and or mentally:
How many days per week do you work out:
I desire to gain lean mass:
I would like to lower my body fat percentage:
Physical Data
SSRI Agreement *
If interested in the Elite Hot Rocs Thermogenic, this box must be checked / acknowledged.

FAST AND EASY.

START IMPROVING YOUR BODY IN THE NEXT 7 DAYS.

You deserve convenient and comprehensive wellness options to keep your body running at peak performance.

Our streamlined process is simple.

Book a free Telehealth visit with one of our expert medical professionals, and find out what your body needs to reach your goals.

GET STARTED

Get What Your Body Needs In 3 Simple Steps

Step 1

Book TeleHealth Call

Step 2

Complete Lab Work

Step 3

Get Meds In 3-5 Days

GET STARTED