Nicole is currently accepting new patients. Please complete the form below if you are interested in becoming a patient.

Legal Name

Full legal name, no nicknames please

First Name

Last Name

Phone number

Date of birth

YYYY

What are your most pressing health concerns or goals?

Please list the top 3

Do you have any past or current medical diagnoses?

Please list and include year of diagnosis.

Are you currently under the care of any other providers?

Please list the name of the provider, their specialty, and the condition for which they are treating you.

What have you tried before? Diets, supplements, treatments, etc.

Was it helpful? Unhelpful? Please describe

If you are seeking fertility support - is your partner able to participate?

Please describe level of involvement and emotional of logistical roadblocks if relevant.

I understand that this work incorporates conventional medical therapies as well as dietary changes, use of nutritional supplements, and lifestyle modifications relating to sleep/movement/stress/chemical exposure/etc. I am willing to engage in these modifications as recommended.

Please be honest as you evaluate your response.

I understand that Nicole is an out-of-network provider and that I will be provided with a super bill which can be submitted to insurance for out-of-network coverage based on my individual insurance plan. Patients may use HSA/FSA funds to pay for clinical services. Lab work and prescription medications are covered at regular in-network rates per my individual plan.

Yes, I understand

I understand that Nicole is not a primary care provider and I have a primary care provider in the community.

Yes, I understand

Questions?

Most new clients have a question or two. Feel free to drop them here and we can discuss before scheduling an initial consultation.

Digital signature

I agree I have read and understood the above items.