Request a Private Consultation

Before you share health information, please read how Meridian Concierge Health handles it. We use what you enter and upload to coordinate a private consultation. Lab documents are read by automated services in our AWS account to prepare a summary for your concierge. Records reach the treating practice only under an authorization you sign. We use service providers such as AWS, Stripe, and Calendly, and we never sell your information. If a sales representative referred you, they see only whether your inquiry was received and a consultation reserved, never your health information. You can ask to access, correct, or delete your information at any time.

Read the full Privacy and Data Use Notice (Effective October 9, 2026; opens in a new tab)

I have read the Privacy and Data Use Notice and agree to how my information is collected, used, and shared as it describes.

By accepting electronically, you agree that your electronic acceptance is your signature and that this document may be provided to you electronically. You can print or save a copy now, and you can ask ops@meridianconcierge.health for a paper copy at any time.

If a treatment plan is recommended, what investment range are you comfortable considering?

Do you currently have a primary care physician?

YesNo

Recent lab results (optional)

If you have recent lab work, you may upload it to help our team prepare for your consultation.

These are values extracted from documents you uploaded, shown for your and your physician's reference. They are not interpreted, and nothing here is a diagnosis or medical advice.

Lab documents can be attached once your privacy notice acknowledgement on step 1 is recorded.

Identity

First name

Last name

Date of birth

Sex assigned at birth

MaleFemale

Height

Weight

Email

Mobile phone

Mailing address

Street address

Address line 2

City

State / region

ZIP code

Country

How did you hear about us?

Do you have any known allergies?

NoYesNot sure

Have you been diagnosed with an autoimmune condition?

NoYesNot sure

Cancer history

NeverCurrentPast / in remissionNot sure

Have you ever received an organ transplant?

NoYes

Have you had surgery within the past 6 months?

NoYes

Do you currently take prescription medication?

NoYes

Do you currently use NSAIDs such as ibuprofen (Advil/Motrin), naproxen (Aleve), or prescription anti-inflammatory medications?

NoOccasionally / as neededRegularlyNot sure

Do you regularly take supplements or vitamins?

NoYes

Acknowledgement and signature

This intake is for concierge coordination. Completing it does not establish a physician-patient relationship, does not determine candidacy, and is not clinical consent. Eligibility for any service is determined only through individualized physician evaluation when clinically appropriate and where legally available. Individual results vary.

By signing, you confirm the information is accurate to the best of your knowledge. This electronic signature records your acknowledgment of the coordination terms. It is not informed consent for any procedure.

I agree to the Terms

Sign to confirm the information is accurate

Date of signature

Optional coordination texts

Meridian Concierge Health may send optional coordination text messages to a mobile number you provide — for example scheduling, document requests, and appointment reminders. Message frequency varies. Message and data rates may apply. Texts are coordination only and will not include diagnoses, lab results, therapy names, or other clinical content. Consent is not required to request a consultation. Reply STOP to cancel, HELP for help. See https://meridianconcierge.health/privacy and https://meridianconcierge.health/terms.

I agree to receive coordination text messages from Meridian Concierge Health at the mobile number I provided. Message frequency varies. Message and data rates may apply. Reply STOP to cancel, HELP for help. Consent is not required to submit this inquiry. Texts are coordination only and will not include clinical details.

Request a private consultation.

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private consultation.