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Dr ALEXIS SHIELDS
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New Client Application
To determine whether health consulting is a good fit, please complete this short 5-minute application. I’ll follow up by email with your best options.
What is your legal first and last name.
(Required)
First
Last
Preferred name (optional)
First
Email address
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Email
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*Please include your best and most frequently checked email.
Where do you live?
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In the United States
Outside of the United States
*Please check the box that reflects where you would complete your blood test.
In what city and country do you plan to complete your blood test?
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Do you live in New York, New Jersey, or Rhode Island?
(Required)
No
Yes, I live in NY, NJ or RI.
Date of birth (YYYY/MM/DD)
(Required)
YYYY slash MM slash DD
Sex assigned at birth
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Female
Male
Intersex
Prefer not to say
*This information helps ensure accurate blood test ordering and interpretation.
How did you hear about us?
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*Please be as specific as possible so we know who or what to thank.
Please briefly list your top 3 most important health concerns or goals.
(Required)
What are you hoping to achieve from a consultation with me?
(Required)
Are you willing and ready to make changes to your diet, fitness, and lifestyle routines that are necessary to improve your health?
(Required)
Yes
No
Do you have any additional questions or concerns you’d like me to address when I contact you?