Dr. Nicole Lewis
Thank you for taking the time to answer my questions! I am so excited to know you better. Your answers to the following questions will help me to better serve you going forward. Please keep an eye on your inbox for next steps.
Email *
Name (First and Last) *
Phone number
Age *
What state do you reside in? *
How committed are you to making lifestyle changes? *
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100%
What about your top 3 health concerns? *
If you could wave a magic wand and improve 2 things about your health, what would they be? *
Have you been diagnosed with any of the following?  *
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Who else have you worked with for these concerns? *
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Do you tend to have questions or concerns in between scheduled visits? *
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What types of labs testing have you done? *
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Did the above testing result in any significant findings? *
What previous therapies or lifestyle changes have you tried that worked? *
What would you be able to accomplish if you were feeling your best? *
What is getting in the way of reaching your health goals? (Be as specific and honest as possible.) *
What is your current diet like? Please be specific (Breakfast, Lunch, Dinner, Snacks) *
Are you taking any medications or supplements? Please list what you take and what it is for.  *
How do you CURRENTLY feel when you wake up in the morning? *
How do you WANT to feel when you wake up in the morning? *
What characteristics do you value in a professional relationship? *
If we were to work together, what would you expect to achieve from working with me? *
Dr. Lewis offers many options to meet you at the level you need for your health. Please check all that apply so we can best supply you with options that fit your style and budget.  *
Required
Were you referred to Dr. Lewis? *
If so, by whom? We would love to thank them!
THANK YOU!
After your application is reviewed, we will contact you via dr.nicolelewisnd@gmail.com with options. Please add this email to your approved senders list. If you do not receive a response within 1 week, please check your spam folder and call 970-408-0759. Every application is reviewed personally. Thank you for allowing us to be a part of your journey to health and healing
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