Consultation Request

If you would like to request your FREE consultation, please fill out and submit the form below. Thank you.

Name*

Last name

Your email*

Gender*

Are you inquiring for a minor? Yes or No*

Do you smoke? Yes or No*

Any documented medical diagnosis you've received? (Please list)*

Have you tried any health supplements, therapies, or treatments in the past? (Please specify)*

Please check your current physical, emotional or mental complaints:*

Fatigue

Sleep Issues

Focus / Brain Fog

Gut Issues (bloating, digestion problems, etc.)

Weight Loss Struggles

Emotional Stress / Anxiety

Mental Health Challenges (depression, mood swings, etc.)

Other (Please specify in comment box below

Additional Comments about your current physical, emotional, or mental complaints*

Out of the above concerns, which ONE would you like to target first?*

On a scale from 1 to 10, how ready are you to incorporate potential solutions into your routine? (1 = Not ready at all, 10 = Fully committed)*

Budget? Our wellness protocols can range between $75 - $350 per month. Is this within your estimated budget for health solutions? Yes or No

Is there anything else you'd like to share regarding your health journey or specific concerns?*

drfadwapharmd@gmail.com