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Wellness+ Consult
Please complete this confidential form before your virtual consultation. This helps us personalize your care plan and ensure a smooth experience.
Name
*
First Name
Last Name
DOB
*
-
Month
-
Day
Year
Date Of Birth
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Gender
*
Male
Female
Height
*
(5'7"...)
Weight (Current)
*
(155 lbs)
Occupation
*
(Salesman, Manager, Carpenter, Teller, etc)
Who referred you to Wellness+?
Lifestyle & Goals
Any current diagnoses?
*
No
Yes
Lifestyle Choices:
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Sedentary
Active
Athlete
Primary Goals (Multiple Choice / Checkboxes):
*
Fat Loss – Burn fat, improve metabolism, and retain muscle
Muscle Building – Increase lean mass and recovery
Sexual Health – Boost libido, stamina, and fertility
Anti-Aging – Optimize hormones, cellular health, and skin
Joint/Recovery – Heal tendons, ligaments, reduce inflammation
Cognitive Enhancement – Improve focus, memory, clarity
Athletic Performance – Increase stamina, recovery
Appetite Control – Suppress cravings and manage weight
What are you hoping to achieve with TRT/HRT/Peptides?
*
Health History
Any current diagnoses?
*
No
Yes
If Yes, please explain more:
Any current medications or supplements?
*
No
Yes
If Yes, please explain more:
Protein powder, creatine, etc
Any history of hormone-related conditions?
*
No
Yes
If Yes, please explain more:
Protein powder, creatine, etc
Previous experience with TRT/HRT/Peptides?
*
Beginner – I don’t know anything (that's ok)
Intermediate – I know some
Advanced – I know a lot
Upload Bloodwork (Must be within last 6 months)
Browse Files
Drag and drop files here
Choose a file
If you do not have it, it's ok.
Cancel
of
Medical Provider Info
Do you currently have a prescribing doctor?
*
Yes
No
Do you need help finding one?
*
Yes
No
Lifestyle Commitment
Are you open to making lifestyle changes to optimize results?
*
Yes
No
Maybe
On a scale of 1–5, how committed are you to your goals?
*
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Consent & Signature
Checkbox: I confirm that the information provided is accurate and complete.
*
Confirm
Signature
*
Date
*
/
Month
/
Day
Year
Date
Consult Selection & Payment
If you have bloodwork ready and need a W+ protocol for medication approval, choose the Bloodwork & W+ Protocol Consult. If you only want to discuss your health or ask questions, select the General Consult Call.
👇 Tap "Circle" to select consult type:
*
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( X )
Professional Consult + Bloodwork Analysis - 45 minutes
Submit recent bloodwork and consult with a specialist to develop a personalized W+ protocol for medication approval.
$
50
General Consult Call
Schedule a call to discuss questions, concerns or general topics with specialist. (No Bloodwork or Protocol Required)
$
Free
Payment Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Now, Time to Book!
Thank you for completing this form. Be sure to complete the booking to lock in your appointment time.
PIck Your Consult Day/Time:
*
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