New client

Results Explained, Intake

You've already done the hard part, you got tested. This short form helps us understand what you're bringing us and what's on your mind before your session.

Client Information

Full Legal Name *

Preferred Name

Date of Birth *

Mobile Phone *

Email Address *

Primary Care Provider (optional)

How did you hear about us?

What Are You Bringing Us?

Select every report you'd like reviewed. Your price is calculated based on your selections.

Date(s) of Testing

Where Was Testing Performed?

Your Concern

What's your main concern or question about these results?

Has anyone already explained these results to you? If so, what were you told?

On a scale of 1, 10, how worried are you about what these results might mean?

Not worriedVery worried

Consent & Signature

I understand that Results Explained is an educational review and interpretation of test results I have already obtained, and is not a new diagnostic test, a medical diagnosis, or a substitute for follow-up with the ordering provider. I understand the practitioner reviewing my results did not order these tests (unless otherwise noted) and is providing guidance based on the information I provide and the reports I submit. I confirm the information above is accurate and complete to the best of my knowledge, and I authorize review of the report(s) I have uploaded.

Client Signature *

Sign with your mouse or finger.

Date *

After you submit: our office will call you at the number provided to collect payment and schedule your virtual consultation. You do not pay through this form.

Your information and files are submitted over a secure connection and stored privately.