Healing and regenerative therapies

Health Information

Please list any current medical conditions you have:

List any medications you are currently taking, including supplements:

Have you had any surgeries in the past 5 years?

Yes
No

Please provide details

Are you currently experiencing any of the following symptoms?

Please check all that apply

Please specify

Treatment Interest

Which of the following regenerative treatments are you interested in?

Please check all that apply

Treatment History

Have you previously undergone any regenerative treatments?

Yes
No

Please specify

Please specify which

Describe your experience

What are your primary goals for seeking regenerative treatments?

e.g., pain relief, improved mobility, hair regrowth, enhanced sexual health

Lifestyle

Please describe your typical daily diet:

What does your exercise routine look like?

type, frequency, intensity

Do you use tobacco products or consume alcohol?

Yes
No

Please describe frequency and quantity

Expectations and Concerns

What are your expectations from the regenerative treatments you are interested in?

Do you have any concerns or questions about the treatments listed?

Yes
No

Please specify

Please indicate your preference for the consultation

In-person
Online
Phone

Are you interested in proactive healthcare and preventative measures to optimize your health and longevity?

Yes
No

Do you stay active and prioritize healthy lifestyle habits like exercise and nutrition?

Yes
No

Would you be open to exploring evidence-based, cutting-edge therapies for anti-aging and wellness?

Yes
No

Are you comfortable providing recent blood work or participating in a comprehensive health assessment?

Yes
No

Do you believe in a collaborative approach to healthcare, working with medical professionals to achieve your goals?

Yes
No

Enter your zip code

We need to make sure your state allows telehealth.

Name

First

Last

Email

Phone

How did you hear about us?

Please specify

Our clinic is located in Hallandale, Florida, are you nearby?

Yes
I can make it
No, but I'm OK with a virtual consultation

If you live far, we do offer virtual consultations