check

Prospective Patient Application to Work 1:1 with Dr. Buttler

Want to find out if my approach is right for you?

Fill out this brief application and my team will be in touch!

Can't wait to meet you!

Click the button below to start.

 

Start

Question 1 of 19

Name (First, Last)

Question 2 of 19

Complete Address (Street, City, State, and Zip Code)

Question 3 of 19

Best Contact Phone

Question 4 of 19

Date of Birth

Question 5 of 19

How did you hear about Dr. Buttler?

Question 6 of 19

Please list briefly what you are looking to address in your health with Dr. Buttler?

 

Question 7 of 19

Do you have medical conditions Dr. Buttler should be made aware of? If so, what are they?

 

Question 8 of 19

Are you taking any prescription pharmaceutical medications? (please do not list supplements, only prescribed medications)

Question 9 of 19

How long have you been experiencing your symptoms?

A

<6 months

B

6-12 months

C

1-3 years

D

3+ years

Question 10 of 19

Have you worked with another doctor for these issues?
(yes/no) (if yes, please explain more)

Question 11 of 19

What is your vision of what you want your health to look like?

 

Question 12 of 19

What role do you want Dr.Buttler to play in your healthcare? (i.e., general health advice, someone to create a specific treatment plan to recover my health, someone to manage my labs and medications, etc.)

Question 13 of 19

Are you willing to change your diet?

A

Yes

B

No

Question 14 of 19

Are you willing adopt a regular movement plan?

 

A

Yes

B

No

Question 15 of 19

Are you willing to take supplements to recover your health?

 

A

Yes

B

No

Question 16 of 19

Your health is an investment that has the potential to save you thousands of dollars in future medical bills! How much are you willing to budget per month to fully recover your health?

A

<$500

B

$500-$1000

C

I'm priceless

Question 17 of 19

On a scale of 1-10 (1= I do not want to change anything, and 10= I am willing to change anything and everything if needed), how committed are you to addressing the underlying cause of your health concerns?

A

1

B

2

C

3

D

4

E

5

F

6

G

7

H

8

I

9

J

10

Question 18 of 19

Is there anyone else involved in your health and financial decision-making process? (i.e. spouse, family member, etc)

A

No, just me.

B

Yes, I have another family member I need to consult with before making this decision.

Question 19 of 19

For fun, if you could have dinner with 2 people (not family) alive or dead, who would they be?

Confirm and Submit