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Type of inquiry Type of inquiry Curious Future Patient Active Patient Former Patient

Visit Type Visit Type Virtual In Person

If In-Person, Then Select Preferred Equilibrium Location If In-Person, Then Select Preferred Equilibrium Location Southlake Houston - River Oaks North Dallas – virtual only at the time Frisco – virtual only at the time Fort Worth - virtual only at the time

Reason for contact (select one or more) Reason for contact (select one or more) Weight loss PCOS Thyroid Assessment Hormone Re-Balancing Therapy Type 2 Diabetes / Insulin Resistance Vitamin & Amino Injection / Infusion Therapy Nutrition Consultation & Planning Eating Disorder Evaluation Other

Receive Future Communication From Equilibrium Via Email / Text / Phone Receive Future Communication From Equilibrium Via Email / Text / Phone Yes No