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HOME

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.

Please don’t forget to fill out the form fields, check the agreement box, and hit submit, but you can also reach us via email at: consults@revelationpharma.com.

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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