Radiate Wellness New Client Application
Please carefully enter the information required below.
"*" Indicates required field.
Please tell us about yourself
First Name*
Last Name*
Preferred Name/Nickname
Date of Birth*
Email*
Phone*
What is your preferred method of communication?
Text
Phone Call
Email
City*
State*
Insurance information
Do you have a HSA or FSA as part of your insurance coverage?
Please confirm that you understand, nutritional therapy and advanced testing are not covered by standard insurance plans at this time. Reimbursement is an option if you have an HSA/FSA. Otherwise, services are cash pay.*
Confirmed
How can we support you?
What program are you interested in?*
Nutrition Therapy $600 / 4 Session Package
3 Month Hormone Accelerator $2500 / Bi Monthly Consulting + Hormonal Testing
6 Month Functional Reset $5000 / Bi Monthly Consulting + Testing
How did you hear about Radiate Wellness?*
Please list your top 3 symptoms, in order of severity.*
Have you ever worked with a Functional Medicine Doctor or Functional Nutritionist?*
Yes
No
What do you want from working with a functional nutritionist?*
At Radiate Wellness, your goals and health aspirations are important to us. What are your 3 main health goals?
Health Goal #1*
Health Goal #2*
Health Goal #3*
Can we stay in touch?
Would you like to be added to our newsletter list?*
Yes
No
Submit