Be Well BioSync™ - Intelligent Health Inquiry

Personal Information

How did you hear about us? *

First Name *

Last Name *

Date of Birth *

Gender at Birth *

Mobile Phone *

Email Address *

Address

Street Address

Apartment, Suite, etc. (Optional)

City

State

ZIP Code

Preferred Clinic Location *

Insurance Information

Insurance Card (Front & Back)

Click to upload insurance card images

Driver's License or ID

Click to upload ID

Is the insurance under your name? *

Services & Goals

What brings you to Be Well? *

What are your primary health goals? *

Are you interested in our 12-Week Total Transformation Program?

When would you like to start your wellness journey? *

Preferred appointment times

Health History

Do you currently experience pain or discomfort? If yes, please describe:

Have you received any of our services before? If yes, which ones?

Current health conditions or concerns:

Current medications:

Current supplements:

Past surgeries or hospitalizations:

Alcohol consumption:

Tobacco/Nicotine use:

Do you follow any special diet?

On a scale of 1-10, how motivated are you to achieve your health goals? *

1 - Not motivated 10 - Extremely motivated

5

What obstacles might prevent you from achieving your health goals?

Medical Documents (Optional)

Recent Blood Work

Click to upload blood work results

X-rays, MRI, or Other Medical Records

Click to upload medical records

Review Your Information

Please review your information below. Click "Edit" to make changes to any section.

BioSync Health Assessment

Personal Information

Address

Insurance Information

Primary Insurance Holder Information

Services & Goals

Health History

Medical Documents (Optional)

Review Your Information

Personal Information Edit

Insurance Information Edit

Services & Goals Edit

Health History Edit

Consent & Electronic Signature

BioSync Health Assessment

Personal Information

Address

Insurance Information

Primary Insurance Holder Information

Services & Goals

Health History

Medical Documents (Optional)

Review Your Information

Personal Information Edit

Insurance Information Edit

Services & Goals Edit

Health History Edit

Consent & Electronic Signature

Full Disclosure

Assumption of Risk

Release of Liability