Application for the Thyroid Reset Program

Before scheduling a call, please complete this short application so we can better understand your symptoms, history, and goals.

As this is a personalized, high-level program, we carefully review each application to ensure it’s the right fit before moving forward with a call.

Full Name

Email *

What's your cellphone number? *

I agree to receive text messages from Inner Vitality Company regarding my application, appointments, and services. Message frequency may vary. Message & data rates may apply. Reply STOP to unsubscribe or HELP for help.

How old are you? *

Where are you located? *

Have you been diagnosed with any of the following? (Check all that apply) *

Hashimoto’s

Hypothyroidism

Hormone Imbalance

Insulin Resistance

Gut Issues / IBS / Bloating

Autoimmune Condition

None / Unsure

Which symptoms are you currently struggling with? (Check all that apply) *

Fatigue / Low Energy

Weight Gain or Difficulty Losing Weight

Brain Fog

Poor Sleep

Digestive Issues / bBoating

Hair Thinning

Anxiety / Mood Changes

Hormone Imbalance

Are you currently taking thyroid medication? *

Yes

Not Sure

How long have you been struggling with these symptoms? *

Less than 1 year

1–3 years

3–5 years

More than 5 years

Not sure how long

What is the main result you want to achieve from improving your health? *

If we determine you are a good fit for our personalized functional medicine program, which may require an investment of $5,000+, are you open to making that investment to restore your health? We have financing options and accept HSA/FSA, major credit cards. *

Yes

Not at this time

On a scale of 1–10, how committed are you to improving your health right now? *

Is there anything else you'd like Dr. Christina to know before your consultation? *

Why is it important for you to solve this problem now? *