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Contact Information
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First Name
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Last Name
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Email
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Phone Number-required if you desire to receive text messages
zip code
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How did you find out about us?
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Referred by a friend
LinkedIN
Face Book
You Tube
Instagram
TV/ Radio/ Print
Podcast
Attended a Masterclass online
I am a previous patient of Dr. Simmons Clemmons
How can we help you?
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General
Diagnostic Consultation
Programs and Resources
Institutional/Professional Inquiry
(All of the following questions are Optional but helpful) What is keeping you from reaching your goals?
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Lack of Awareness: Many people are not aware of the risk factors/prevention for various illnesses.
Lifestyle Factors: Unhealthy lifestyle factors: poor diet, lack of exercise, or smoking .
Genetics: Can affect disease prevention & management.
Access to Healthcare: Many people may not have access to affordable healthcare.
Stigma, discrimination : Can block mental health an other treatment.
Financial Burden: The cost of healthcare and medications can be a significant financial burden.
Language & cultural barriers: Can hinder healthcare access & understanding.
Chronic conditions: Requiring continuous care & lifestyle changes.
Lack of support: makes illness management difficult.
Motivation: affects illness prevention & management.
Have you tried any health products or services in the past? If so, which ones worked for you and which ones didn't?
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What are your primary sources of health information? Do you rely on doctors, online resources, or other sources?
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Doctors
Online Resources
Other
What are your preferred methods of receiving health information and support? Do you prefer in-person consultations, telehealth services, online communities, or other methods?
In-person Consultations
Telehealth
Online Communities
Email newsletters
Other
What are your lifestyle habits and preferences? Do you prefer natural remedies, fitness programs, dietary supplements, or other approaches to health and wellness?
Natural Remedies
Fitness Programs
Dietary Supplements
Spiritual Inspiration and Divine intervention
Other
What treatments or approaches have you tried so far?
Medication
Nutrition
Exercise
Biblical Approach to Health
Other
What factors influence your decision to purchase health products or services? Do you prioritize cost, convenience, effectiveness, or other factors?
Cost
Convenience
Effectiveness
Alignment with Scriptural Values
How do you want to approach your health going forward?
Holistically
Being Made Whole
Both
Someone from our staff will be in touch with you shortly. State your best date and times as well as email or phone preference. If you have a concern not listed above briefly state it here
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