Consult Application Form

Dr. Leott's Midlife Health Clarity Consultation

You're taking the first step toward making sense of what's happening with your health in midlife. This short intake helps me understand your biggest questions and concerns before we talk.
Once your intake and payment are received, you'll receive a link to choose your consultation time. Please allow about 5 minutes to complete the form.
Name

First NameLast Name
Date of birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
What would you most like help understanding or sorting out during our consultation?
What are your top 3 symptoms, concerns or health goals right now?
Which areas would you especially like us to look at?

Other
Are you currently working with a healthcare provider for any of these challenges?
Have you had any lab testing in the past year?
What have you already tried?

Other
What were you hoping these would help you with?
Of the things you tried, what helped and what didn't?
Are you currently on any prescription hormones?
Approximately how many prescription medications and supplements do you currently take?
Any major health conditions you feel are important to mention?
What would you say your current level of stress is?
How would you describe your sleep?
Is there anything else you would like me to know about you?
If you could leave our consultation with ONE question answered or ONE thing clearer, what would it be?
Please read and accept the following:

Dr. Leott's Midlife Health Clarity Consultation

$149.00 Quantity

Total

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