— new member intake —

The first conversation.

Below is a 12-minute intake. We use it for two things: to schedule a free 30-minute discovery call, and to make sure your first appointment in the practice is actually useful. Personally read by our medical director.

Become a member.

~ 12 minutes · personally read · response within 2 business days ~

— I. WHO YOU ARE

First name

Last name

Date of birth

Pronouns

Phone

City you live in

— II. WHAT YOU'RE LOOKING FOR

Which membership tier are you considering?

— foundation —$3,400/yr — cornerstone —$6,800/yr — deep —$14,000/yr

What brought you here today?

If we work together for a year and only one thing changes, what is it?

— III. YOUR HEALTH NOW

Height

Weight

Current medications (over-the-counter included)

Significant medical history (one-line summary, if comfortable)

— IV. HOW WE WORK

★ I understand Your Business is a direct-pay membership practice and does not bill insurance.

★ I understand membership covers our practice; I should retain catastrophic / hospitalization insurance separately.

I authorize Your Business to securely receive medical records from my previous physician, if applicable.

~ HIPAA-secured · personally read by Dr. Park · response within 2 business days · no automated emails ~