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I'M A PATIENT

I'M A PROVIDER

SHOP

OUR TEAM

PATIENTS | GET IN TOUCH

PROVIDERS | GET IN TOUCH

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PATIENT REQUEST FORM

Tailored Guidance for Root-Cause Health Issues

Struggling with unresolved health issues? ConsultRX offers personalized, root-cause-focused solutions nationwide. Fill out this form for expert guidance without any obligations, tailored for your well-being.

Fill out the form below for a downloadable FREE GIFT!

Gender

How would you prefer to be contacted?

What type of health coaching or consulting are you interested in? (Select all that apply)

Individual Virtual or Phone Appointment - I need to see where to get started.

Reduced Cost Package - I’d like to save by getting a package of appointments to better ensure I reach my health goals with continued follow-up.

Group Coaching - I’d like to have my own private appointments for my personal and private goals, but would also enjoy being in a group of people trying to achieve similar goals and supporting one another. (Ex: Weight loss, Women’s Health, Men’s Health)

Email Consult - I just have some questions I’d like feedback on first.

What are the primary health concerns you’d like to address? (Select all that apply)

Medication Therapy Management

Functional & Holistic Approach to Chronic Disease

Hormone Management & Optimization

Nutrition & Supplement Coaching

Weight Management

Stress, Energy, & Sleep Management

Gastrointestinal and/or Immune Management

Sexual Health Concerns (All Genders)

Dermatological & Cosmeceutical

Other (Please Specify):

If "Other" was selected from the list of health concerns above, please provide information below.

Do you currently have a Provider open to prescribing BHRT in your area?

Yes

Are there any other health concerns you’d like to address?

By Checking this Box, I agree to the HIPAA Disclaimer that my information is protected and I have a right to my personal health information. I also agree to be contacted regarding my inquiry.

Thank you for your interest in ConsultRX and we look forward to speaking with you soon!

Phone: (943) 200-7948
Email: consults@revelationpharma.com

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