VERIFIED-WELLNESS INSTITUTE

Health Readiness Screening

At Verified Wellness Institute, we practice data-driven, personalized care. Most applicants are required to complete comprehensive lab testing before their initial consultation to ensure safety, accuracy, and individualized recommendations.

BASIC INFORMATION

Full Name

Date of birth

Biological Sex (for medical purposes)MaleFemale

Height

Current Weight

Phone

YOUR GOALS

(Select all that apply)Weight or body composition optimizationHormone optimization (men’s or women’s health)GLP-1 / metabolic supportLow energy, fatigue, or burnoutCognitive or performance optimizationLongevity and preventative healthRecovery, inflammation, or injury supportI’m not sure and want guidance

HEALTH BACKGROUND

(Select all that apply)Prediabetes or Type 2 diabetesThyroid disorderHigh blood pressure or heart diseaseHormonal imbalance (low testosterone, PCOS, etc.)Autoimmune or inflammatory conditionAnxiety or depressionNone of the aboveAre you currently taking prescription medications?YESNO

PRIOR EXPERIENCE

Have you previously used any of the following?(Select all that apply)GLP-1 medications (Semaglutide, Tirzepatide, etc.)Hormone therapy (TRT, estrogen, progesterone)Peptide therapyIV or injectable therapiesNONEIf yes, were labs completed before starting treatment?YESNONOT SURE

READINESS & LABS

Which best describes your current approach to health?(Select all that apply)I want a quick fixI want sustainable, data-driven improvementI want performance and longevity optimizationI’m exploring options but serious about next stepsAre you open to completing comprehensive lab testing before your consultation if recommended?YESNOI want to learn more (link to schedule free 20-min consultation)

WHY LABS COME FIRST

(Informational – Read Only)

Symptoms often overlap and can be misleading.
Comprehensive lab testing allows us to:
‍
- Identify root causes
- Reduce unnecessary or ineffective treatments
- Customize protocols safely and accurately

For most applicants, labs are the first and most important step in the process.

ACKNOWLEDGMENT & CONSENT

I understand that eligibility does not guarantee acceptance into a programI acknowledge that lab testing may be required before consultationI consent to be contacted regarding next steps

Electronic Signature

PLEASE TYPE FULL NAME

*Once you click submit, you will be redirected to a calendar scheduler to book your free 20-minute consultation.

Thank You for Completing the Eligibility Screening

Our clinical team will review your responses.
If eligible, you will receive instructions to complete comprehensive lab testing prior to scheduling your consultation.
Most applicants receive next-step instructions within 24–48 business hours.

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