HOWTOLIVEYOUNGER Email Marketing -

Let's find out if we are a great fit for each other and how we can serve you!

Finding a new practitioner can be scary and frustrating. You want to know ahead of time if you can relate to the doctor and be sure they can help you. You want to know the process and next steps. Please fill out your information below and if you are a good fit, we will schedule a free, no obligation discovery call so we can determine if we can help. If that is the case, you will be invited to come in for a paid consult and once we know the complexity of your case you will be directed to a program which you are free to participate in or opt out with no obligation or hard feelings. We want people we can help and are motivated to do what it takes to be healthy and we know you want to be sure you have a doctor who you can relate to, takes you seriously, listens and has helped people like you.

First Name*

Last Name*

Cell Phone Number*

Email Address*

What is your top challenge that you would like us to help you overcome?*

Why is this goal important to you?*

What is stopping you from accomplishing this goal?*

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

To say it was a success working together what is the outcome you need? What would “done” look like?*

What do you think is missing (or was missed) in your prior treatment, regarding getting the answer(s) or outcome you would like for your particular situation?*

How urgent is it for you to overcome this challenge?*

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

Have you experienced significant trauma (emotional, physical)?*

What are the characteristics that you value most in a healthcare partnership?*

How familiar are you with functional medicine?*

Not at all

Somewhat

Familiar

Very familiar

What functional lab testing have you had done?*

Functional Stool Testing

Organic Acids Testing

Genetic or Genomic Testing

Hormone Testing

Heavy Metal Testing

Food Allergy Testing

Micronutrient Testing

None

Other

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

Yes

No

If we can find a natural solution to permanently address your health issues, how much would you be willing to invest in a solution that works for you? Please be as accurate as possible here. Your response doesn’t change our pricing..but it helps us understand your budget, coaching support options and testing options within your budget and importance.*

Please choose your primary area of interest. *

How did you hear about us?

After submitting this form, you will be forwarded to a page to learn more about functional medicine, the programs we offer and frequently asked questions to get the most out of our free, no obligation clarity call.

We look forward to working with you :)