Registration Form for Supplement Support -

Patient Information

Patient Name

First

Last

Date of Birth

Age

Biological Sex

Phone Number

Email Address

Best Way to Reach You

New or Returning Patient?

Your Chronic Conditions

Check any conditions you have been diagnosed with or are actively managing.

Autoimmune & Inflammatory

Metabolic, Endocrine & Hormonal

Cardiovascular

Digestive & Gut

Neurological, Cognitive & Mental Health

Chronic Fatigue, Pain & Complex Illness

Skin, Women's & Men's Health

Other Chronic Conditions

What Symptoms Are You Most Looking to Improve?

• How Much Do Your Symptoms Affect Daily Life?

Other Providers You Currently See?

Relevant Lab Results

Vitamin D Level

Vitamin B12 Level

Ferritin / Iron

Thyroid Status

HbA1c (Blood Sugar)

Inflammation (hs-CRP)

Homocysteine / Methylation

MTHFR Genetic Variant

Current Supplements

All Current Supplements With Dosages

Prior Supplement History

Preferred Supplement Form

Supplements You Have Had Negative Reactions To

Monthly Supplement Budget

Willing to Take How Many Supplements Per Day?

Lifestyle Factors

Negative Per (type

Current Weight (lbs)

Height

Average Sleep Hours Per Night

Sleep Quality

Stress Level

Exercise Frequency

Daily Water Intake

Alcohol Use

Tobacco or Nicotine

Pregnancy Status (if applicable)

Timeline Expectations

Consent and Signature

Please read and confirm each statement below before submitting.

Accuracy

I confirm the information above is accurate and complete, including all medications, supplements, allergies, and medical conditions.

Complementary Care

I understand supplement recommendations are complementary to, not a replacement for, prescribed medical care. I will not stop or change any prescription medication without discussing it with the prescribing provider.

FDA Statement

I understand dietary supplements are not evaluated by the FDA to diagnose, treat, cure, or prevent any disease.

Consultation Required

I understand a consultation with Dr. Thomas is required before a supplement protocol is designed, and additional lab work may be recommended.

Emergency Care

I understand this form does not replace emergency care. I will call 911 immediately if I experience a medical emergency.

Contact Consent

I consent to Dr. Thomas’s team contacting me by phone or email to schedule my consultation.

Electronic Signature (type your full legal name)

Today's Date