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Call Today! 513-791-9474

Call Today! 513-791-9474

Schedule an Appointment

Thank you for your interest in our natural hormone replacement, sexual medicine, MedSpa services, and weight loss program. To request an appointment, please fill out the form below. We’ll get back to you within a business day to schedule.

Free Consultation

Name*
First Last
Phone*
Email*
Address*
Street Address Address Line 2 City State ZIP Code
Date of Birth*
Gender*
- Male
- Female
What is your height?*
What is your weight?*
Emergency Contact Name*
First Last
Emergency Contact Phone*
How did you hear about us?*
- Friend/Family Member
- Radio
- Internet Search
- Social Media
- Other
Friend or family member name*
What Radio Station?*
What were you searching for on the internet?*
What social media site/app did you see us on?*
What other source did you find Your Wellness Center*
Which service(s) will you be visiting our office for?*
- Hormones
- MedSpa
- Weight Loss
- IV Therapy
- Food Sensitivity Testing
- Sexual Medicine
What IV Therapy treatment are you interested in?*
- Get-Up-And-Go
- Recovery & Performance
- Myer's Cocktail
- Immunity
- Alleviate
- Inner Beauty
- NAD+ (250mg or 500mg)
- Vitamin C (Regular 5g)
- High-Dose Vitamin C (25g-75g)
- Amino Blend Injection
- B12 Injection
- Magnesium Injection
If interested in High-Dose Vitamin C, bloodwork and a provider consultation are required prior to starting treatment.
MedSpa Consultation Questions
What service(s) are you interested in?*
- Free Consultation
- Laser Treatment
- Injectables
- Facials
- Microneedling
- Chemical Peel
- Do you have other concerns?
Select all that apply
What skin condition(s) are you looking to treat?*
- Acne
- Anti-Aging
- Melasma
- Rosacea
- Sun Damage
- Scarring/Hyperpigmentation
- Tone/Texture
- Lines & Wrinkles
- Volume Loss
- Do you have other concerns?
Select all that apply
What is your skin type?*
- Dry
- Oily
- Combination
- Sensitive
- Normal
- Not Sure
Select any that apply
Weight Loss Progam
Have you ever been diagnosed with an Eating Disorder?*
- Yes
- No
Please answer: Type of disorder and diagnosis date?*
Reasons for Weight Loss*
Please list your top 5 reasons for weight loss
Medical History
Do you have a history (current or past) of cancer?*
- Yes
- No
Please answer: Type of cancer. Diagnosis date. Remission date.*
Are you pregnant*
- No
- Yes
- Possible
- N/A
Periods are*
- Regular
- Irregular
- None
- N/A
Hysterectomy*
- Full
- Partial
- N/A
Both Ovaries Removed*
- Yes - Both
- Yes - Only One
- No
Endometriosis*
- Yes
- No
Polyps*
- Yes
- No
Fibroids*
- Yes
- No
Date of Last Mammogram*
Date of Last Pap Smear*
Medical Conditions/Symptoms*
- Anemia
- ADD/OCD
- Anxiety
- Arthritis
- Asthma
- Bleeding disorder
- Cancer
- (CHF)Congestive heart failure
- COPD
- Coronary artery disease
- Depression
- Diabetes
- Diverticulitis
- Emphysema
- Gastritis
- Gout
- Heartburn/reflux
- Hepatitis
- Hiatal hernia
- High blood pressure
- High cholesterol
- High triglycerides
- HIV/AIDS
- H‐pylori
- Incontinence
- Irregular heart beat
- Irritable Bowel
- Kidney disease
- Kidney stones
- Liver disease
- Migraines/Headaches
- Polycystic Ovarian Syndrome (PCOS)
- Previous heart attack
- Prostate problems
- Pulmonary Edema
- Rheumatic fever
- Sleep apnea / snoring
- Stent placed
- Stomach ulcers
- Stress urinary incontinence
- Stroke/TIA/seizure
- Substance abuse
- Thyroid problems
- Tuberculosis
- NONE OF THE ABOVE
Medical Conditions/Symptoms - IV Therapy*
- Anemia
- ADD/OCD
- Anxiety
- Arthritis
- Asthma
- Bleeding disorder
- Cancer
- COPD
- Depression
- Diabetes
- Diverticulitis
- Emphysema
- Gastritis
- Gout
- Heartburn/reflux
- Hepatitis
- Hiatal hernia
- High blood pressure
- High cholesterol
- High triglycerides
- HIV/AIDS
- H‐pylori
- Incontinence
- Irregular heart beat
- Irritable Bowel
- Kidney disease
- Kidney stones
- Liver disease
- Migraines/Headaches
- Polycystic Ovarian Syndrome (PCOS)
- Prostate problems
- Rheumatic fever
- Sleep apnea / snoring
- Stomach ulcers
- Stress urinary incontinence
- Substance abuse
- Thyroid problems
- Tuberculosis
- NONE OF THE ABOVE
Medical History - IV Therapy*
- (CHF)Congestive heart failure
- Coronary artery disease
- Previous heart attack
- Pulmonary Edema
- Stent placed
- Stroke/TIA/seizure
- NONE OF THE ABOVE
"Yes" to any of these will require a consultation with the provider prior to treatment.
Do you have any of the following?*
- Protein-C Deficiency
- Protein-S Deficinecy
- Anti-Thrombin III Deficiency
- Factory 5 Liden Deficiency
- G6PD Deficiency
- NONE OF THE ABOVE
Do any of your family members have a history of blood clots or a blood clotting disorder?
- Yes
- No
Have you had a blood clot?
- Yes
- No
Have you had any surgical procedures?*
- Yes
- No
Please list surgical procedures*
Do you take any medications?*
- Yes
- No
Please list medications:*
Do you take any supplements?*
- Yes
- No
Please list supplements:
Do you have any allergies or sensitivities?*
- Yes
- No
Please list allergies or sensitivities:*
Such as foods, environment, medications, latex...etc
Family History
Do any of your family members have any medical conditions?*
- Yes
- No
Please list family medical history*
Such as strokes, heart attacks, stents, diabetes, hypertension, high cholesterol, blood clots, etc.
Hormone Information
Hormone Imbalance Checklist*
- Aches and pains
- Anxiety
- Apathy
- Autoimmune Illness
- Bone loss
- Brittle nails
- Chronic Illness
- Cold body temperature
- Decreased libido
- Decreased mental sharpness
- Decreased muscle mass
- Decreased stamina
- Decreased urine flow
- Decreased sexual satisfaction
- Depression
- Elevated cholesterol
- Elevated triglycerides
- Erectile dysfunction
- Fibromyalgia
- Foggy thinking
- General Fatigue
- Hair loss
- Headaches
- Hot flashes
- Inability to lose weight
- Increased urinary urge
- Infertility problems
- Irregular Menstruation
- Irritability
- Lack of motivation
- Morning Fatigue
- Night Sweats
- Oily Skin
- Painful intercourse
- Prostate problems
- Sleep disturbances
- Susceptible to infections
- Vaginal Dryness
- Weight gain in waist
- Other (list below)
- NONE OF THE ABOVE
Please list OTHER hormone imbalances*
Preferred Pharmacy
Preferred Pharmacy Name
Preferred Pharmacy Address
Street Address City State / Province / Region ZIP / Postal Code
Preferred Pharmacy Phone
CAPTCHA

Contact

Address

7770 Cooper Road #8
Cincinnati, OH 45242

Phone

Phone: (513) 791-9474

Hours of Operation

Monday-Friday: 8:00 AM -4:30 PM

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Schedule an Appointment

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