Care Coordinator Visit — Free

About you

A few basics so a care coordinator can reach you.

First name Last name Email Phone Date of birth Sex State Best time to reach you

What brought you here

This helps your coordinator prepare before the call — nothing here locks you into anything.

What's going on, and why now?

What are you curious about? (check all that apply) GLP-1 weight loss Gut-Brain Rx Tesamorelin (belly fat + muscle) Testosterone (men) Menopause & HRT (women) Regenerative medicine (already diagnosed / joints) Not sure — guide me

Anything you would not consider? (optional) Monthly budget in mind

Health history

Basic background the physician needs to review.

Current medications (include dose if known) Supplements you currently take (optional) Drug or food allergies Past surgeries (optional)

Family history (check all that apply) Dementia / Alzheimer's Parkinson's Heart disease Diabetes

Have you already been diagnosed with a condition you'd like help managing? No Yes

Lifestyle

A quick snapshot of where things stand today.

Height (feet) Height (inches) Current weight (lbs) Waist (inches) Average sleep (hours/night) Alcoholic drinks per week Exercise days per week Daily eating window (hours) Average steps per day Last labs drawn

Can you share recent labs with your coordinator? Yes No Not sure

Review and submit

Confirm everything looks right, then sign below so the physician can review your case. A care coordinator will reach out at the time you gave us.

I acknowledge the Notice of Privacy Practices and sign the Authorization to share my health information with our network's licensed physicians. Type your full legal name to sign

By typing your name below you consent to sign electronically under the federal E-SIGN Act, and agree your typed name is the legal equivalent of your handwritten signature.

I understand this intake is for education and care coordination, not medical treatment, and My4MLife may contact me by email or phone.

✓

You're all set.

Dr. TJ has your intake and will call you soon.

Anything to add? (e.g., “I want to talk about gut health”)

Start a new intake

✓

Got it.

Check your email for a confirmation.

One more step (7 minutes): your MindSpan assessment

It gives Dr. TJ your baseline before the call and unlocks the book, the Logbook, and the app.

Take the MindSpan assessment →

Questions? Email care@my4mlife.com. Medical emergency? Call 911 — this form is not monitored 24/7.

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