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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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How did you hear about us?

Referred by a friend
Referred by a doctor
Google search
Directed to website
Podcast
TV appearance
Attended webinar
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If referred to Simone Medical, by who?

What are the specific health challenges you are seeking treatment & wellness care for?

What are your top areas of concern?

Thyroid
Perimenopause
Menopause
Weight Loss
Men's Health
Hormone Imbalances
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What are your BIGGEST obstacles to achieving your health 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 is not working well
Other - will discuss in call
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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
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Do you have any questions that you want to be sure we address when we speak?

I understand Simone Medical is not contracted with any health insurance company.

Yes, I understand that Simone Medical is not contracted with any health insurance companies.

To ensure we spend time and attention with all of our patients, we are only able to accept new patients who are ready to transform their health. Are you ready?

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