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Hashimoto's Audit Call Application
After you submit this form, a link to schedule your call will appear on the next page.
You MUST click on this link to schedule your call.
This is a recorded Zoom call.
*No medical advice will be given on this call.
If I DO NOT think I can help you, your call will be canceled and alternative recommendations will be sent instead.
Thank you!
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First Name
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Your answer
Last Name
*
Your answer
Email address
*
Your answer
How long have you been struggling with Hashimoto's?
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Less than 6 months
6 months to 2 years
2 to 5 years
5 years +
What are the 3 biggest Hashimoto's symptoms you are struggling with?
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Your answer
What have you tried to resolve your Hashimoto's symptoms?
*
Your answer
Has what you tried help or not helped your Hashimoto's symptoms? Please explain in detail.
*
Your answer
What are the 3 biggest obstacles blocking you from recovering?
*
Your answer
What would you like to change in the next 3-6 months with your Hashimoto's symptoms?
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Your answer
What do you feel is needed to reach that change/goal? (ex: more time, meal plan, etc)
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Your answer
Why is this something you are interested in solving now?
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Your answer
Do you have any dietary restrictions you are unwilling to change?
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Your answer
Do you smoke?
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Yes
No
Past
If you were able to find that missing piece to your Hashimoto's symptoms, are you in a place to dedicate time & energy to reach your goal?
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Yes, I have the time & energy.
No, I am not able to right now
Are you able to financially invest in your health right now?
(*please note that insurance does not cover this program. We will discuss this on the call)
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$600 - $1500
$1500 - $2500
$2500 - $5000
I do not have the funds to invest in myself right now
Is there anyone you make financial decisions with? If so, please have them attend the call.
*
I make financial decisions independently
I will make sure they are on the call
They cannot attend, I will discuss with them after
How did you hear about Dr. Nicole?
*
Referred
Instagram
Tiktok
Google search
Other:
May we add your email to Dr. Nicole's email list?
(these are weekly health related emails and clinic updates)
*
Yes please!
No thank you.
No-showing or canceling less than 24 hours notice for this consult call will not be rescheduled. This takes away the opportunity from someone else which is unacceptable & unprofessional.
*
Yes, I understand.
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