After signing all consents in the link provided, please complete and submit this Medical History form 1 hour prior to your appointment time. Please email [email protected] if you have any questions. Thank you!

First Name *

Last Name *

Date of birth

Email *

State: (Oklahoma Residents Only) *

Please explain the reason for your visit: *

Specify Other:

Females:

Hysterectomy?

Or, last menstrual period:

Please list any surgeries you have had (type n/a if you have not had any surgeries): *

Please list all medications (dose, frequency and reason) you are currently taking (type n/a if you do not take any medications): *

Please list all allergies (type n/a if you do not have any allergies) *

Pharmacy Name & Address: *

Please upload most recent lab results if you have them:

Do you have any questions?

Kindly Note: A $49 service fee is collected at the time of service (at least 1 hour prior to appointment time). This small fee helps honor both your time and mine, and allows me to give you the thoughtful, personalized care you deserve.

It includes:
✔️ Your initial consultation
✔️ A follow-up phone or personalized recorded video if we need to review labs or next steps
✔️ Direct access to me by email or text between appointments, should anything come up

If we find that my services aren’t the right fit for your needs,

I’ll gladly refund the fee—no pressure at all.

My goal is to make sure you feel supported, respected, and truly cared for from the very beginning.

Please click $49 before proceeding with payment *

$ 49

Please note: If you choose to pay via PayPal and your payment is not successfully processed, ensure that your date of birth is entered in the required format (MM/DD/YYYY), including the use of forward slashes

Consents *

I understand and have submitted all consents in the provided link