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Thank you for taking the time to answer the questions as thoroughly as possible. Getting to know you helps us provide the best recommendations, so you can decide if our programs are right for you.

Our goal is to deliver the highest level of service. To exceed your expectations, it is important that we work with people who we can build a relationship with and who are the right fit for our practice.

We look forward to getting to know you and helping you Love the Way You Feel!

Full Name*

Email*

Date of Birth *

Phone*

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?

How did you hear about us?

If referred to SheMD, by who?

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 wellness goals?

Financial

Time- Too Busy

Lack of Knowledge

Too Tired

Don't Know How to Exercise for Optimal Health

Don't Know How to Cook

Current Medical Treatment Not Working Well

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

I understand that SheMD does not accept insurance for these services.

Yes, I understand that SheMD does not accept insurance for these services.

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

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Love the way you look and feel!

Book Your Free 15-Minute Discovery Call