Lab and Test Consultation

Submission Form

Full Name

Date of birth

Email *

Phone *

Preferred Method of Contact

Email

Phone

Text

Appointment Details

Have you scheduled a consultation appointment yet?

Yes

No

(If no, you will be prompted to book after submitting this form.)

Test Type & Details

What type of test(s) are you submitting for review?

If other (please specify)

Test Name(s) and/or Provider (if known): (e.g., CBC, DUTCH, GI-MAP, mammogram, etc.)

Date(s) the test(s) were performed:

Please attach all relevant test results

Current Health Information

What symptoms, concerns, or reasons led you to get this test done? (Please list or describe.)

Do you have any relevant diagnoses or medical history?

Yes

No

If yes, please describe:

Have you reviewed these results with your primary care provider or specialist yet?

Yes

No

If yes, what was discussed? (Brief summary):

Have you made any changes to your health routine (diet, supplements, medications, etc.) since receiving these results?

Yes

No

If yes, please describe:

Goals & Expectations

What would you like to better understand from your lab/test results?

Clarification of what the results mean

Holistic interpretation and root-cause insights

Nutrition and supplement recommendations

Functional or lifestyle guidance based on the results

Other

What is your ultimate goal for your health or next step you'd like to take? (Optional but helpful)

Disclaimer & Consent

Please acknowledge:

I understand this consultation does not replace medical advice from my primary care provider.

I consent to a holistic interpretation of my test results to support my wellness journey.

I agree

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Lab and Test Consultation

Submission Form

Current Health Information

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