New Patient Onboarding Form Name * First Name Last Name What's Your Date of Birth? * MM DD YYYY Phone * (###) ### #### What health condition(s) would you like us to treat (check all that apply). Weight Management Hormone management Thyroid management Gut Health Thyroid nodules Chronic Fatigue / Inflammation Sexual wellness Thyroid nodules PCOS If the options above do not accurately describe the reason for your appointment, please briefly describe it below: Have you been formally diagnosed with any of the conditions for which you are requesting an appointment? If so, by whom? Do you know which of the following tests are you interested in? (check all that apply). Extensive Bloodwork Gut Health Testing – GI Map Dutch Hormone testing Dutch Hormone Cyclic mapping Dutch Adrenal testing Dutch Organic Acid Testing Genetic Testing Other (please briefly describe) Other (please briefly describe) ** Please note – Modern Endocrine does not treat Diabetes, Osteoporosis, Adrenal Nodules, or Pituitary Tumors any longer. We are focusing our efforts on other pillars of health at this time. If you would like us to manage chronic fatigue, weight gain, ect from these conditions we are happy to help with that, but those medical conditions and all medications related to those diseases will need to be managed by your primary care or another provider. ** * I attest that I live in one of the following states that Modern Endocrine holds a license to practice medicine in: OK, TX, GA, IL, OH, MI, AZ, NV, TN Thank you!
