Application

Health Optimization Application

We offer customized coaching and hormone optimization programs designed for individuals ready to take their health seriously.

This short application helps us understand your goals and determine if we're the right fit.

First Name

Last Name

Email

Phone

1. What are you primarily interested in?

8-Week Coaching Program 6-Month Customized BHRT Program Not sure yet — I'd like guidance

2. What are your main goals right now?

Select all that apply

Fatigue / low energy Weight gain or difficulty losing weight Brain fog / poor focus Low libido / sexual health concerns Mood changes (anxiety, irritability, etc.) Sleep issues Hormonal imbalance symptoms Anti-aging / longevity optimization Other

3. How long have you been experiencing these issues?

Less than 3 months 3–12 months 1–3 years 3+ years

4. Have you tried anything in the past to address this?

Yes No

5. How ready are you to start improving your health?

I'm ready to start now Within the next 2–4 weeks 1–3 months Just exploring options

6. Are you willing to follow a structured, physician-guided plan that may include lifestyle changes, lab testing, and ongoing monitoring?

Yes No

Our programs require commitment to a physician-guided plan. This program may not be the right fit at this time, but we appreciate your interest.

7. Have you had any recent lab work done (within the past 6–12 months)?

Yes No

8. What is your age?

Under 25 25–35 36–45 46–55 56+

9. Where are you located?

10. Investment readiness

Our programs are customized and require a meaningful investment in your health. Are you prepared to invest in a premium, physician-guided program?

Yes, I'm ready to invest in my health Possibly, I'd like to learn more No

We understand this may not be the right time. Our programs require a meaningful investment, and we want to ensure it's the right fit for you.

11. What would you like help with that you haven't been able to solve on your own?

12. Why is now the right time for you to make this change?

Submit Application

Your information is confidential and will only be used to evaluate your application.