First Name *

Last Name *

Email *

Phone *

Date of birth

Location *

St. George, Utah

Logan, Utah

Other

What City? *

On a scale of 1-10 (1 being "not at all", 5 being "somewhat" and 10 being "I'm 100% ready!"), how ready are you to commit and make the necessary changes to achieve your goals? *

1
2
3
4
5
6
7
8
9
10
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What are the specific health challenges you are seeking treatment & wellness care for? *

If you could wake up tomorrow without these symptoms, how would your life be different? *

What are your BIGGEST obstacles to achieving your health goals? Choose all that apply. *

Financial

Time (Too Busy)

Lack of Knowledge

Don't Know How to Exercise for Optimal Health

Don't Know How to Cook

Current Medical Treatment is Not Working

Other

What are you looking for most in a health care provider? Choose all that apply. *

Listens to Me

Looks at the Big Picture (Holistic Approach)

Collaborates With Me to Help Me Make the Best Health Decisions for My Circumstances

Looks for the Root Cause of My Medical Problems, Instead of Just Addressing My Symptoms

Do you have any questions that you want to be sure we address when we speak? *

We have more patients apply than we can accommodate. Why do you feel like you are a great fit to work with us? *

How did you hear about us? *

Google Search
Referred By Friend
Referred By Doctor
Practice Event
Podcast
TEDx
Menopause Society
Other
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