Consultation Application to work with Dr. Buttler


Please fill out this brief application and my team will be in touch with you to schedule a 10-minute discovery call (phone or video) with Dr.Buttler to talk about working together. 


Click the button below to start.



Question 1 of 11

Name (First, Last)

Question 2 of 11

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

Question 3 of 11

Best Contact Phone

Question 4 of 11

Best Email Address

Question 5 of 11

Date of Birth

Question 6 of 11

How did you hear about Dr. Buttler?

Question 7 of 11

Please list what you are looking to address with Dr. Buttler?  

Question 8 of 11

Everything Dr.Buttler does is about moving you towards your vision of health. He has seen miracles happen when people have been left hopeless with no other options. What is your vision of what you want your health to look like? 



Question 9 of 11

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

Question 10 of 11

Please read information below and answer question. 

INFORMED CONSENT REGARDING E-MAIL OR THE INTERNET USE OF PROTECTED PERSONAL INFORMATION provides clients the opportunity to communicate with them by e-mail. Transmitting confidential health information by e-mail, however, has a number of risks, both general and specific, that should be considered before using e-mail. 

1. Risks: 

a. General e-mail risks are the following: e-mail can be immediately broadcast worldwide and be received by many intended and unintended recipients; recipients can forward e-mail to other recipients without the original sender(s) permission, or knowledge; users can easily misaddress an e-mail; e-mail is easier to falsify than handwritten, or signed documents; backup copies of e-mail may exist even after the sender, or recipient has deleted his/her history. 

b. Specific e-mail risks are the following: e-mail containing information pertaining to health information must be included in the protected personal health information; all individuals who have access to the protected personal health information will have access to the e-mail messages; clients who send, or receive e- mail from their place of employment risk having their employer read their e-mail. 

2. Email and Internet Policies: 

It is our policy that all e-mail messages sent or received, which concern health information of the client will be a part of that client’s protected personal health information and we will treat such e-mail messages, or internet communications, with the same degree of confidentiality as afforded other portions of the protected personal health information. 

We will use reasonable means to protect the security and confidentiality of e-mail, or internet communication. Because of the risks outlined above, we cannot, however, guarantee the security and confidentiality of e-mail, or internet communications. 

3. Client Consent 

Clients must consent to the use of e-mail for confidential medical information after having been informed of the above risks. Consent to the use of e-mail includes agreement with the following conditions: 

a. All e-mail to, or from, clients concerning health information will be made a part of the protected personal health information. As a part of the protected personal health information, all of our health coaches and upon written authorization other healthcare providers will have access to e-mail messages contained in protected personal health information. 

b. Our coaches may forward e-mail messages within the practice as necessary for coaching purposes. We will not, however, forward the e-mail outside the group without the consent of the client as required by law. 

c. We at will endeavor to read e-mail promptly, but can provide no assurance that the recipient of the particular e-mail will read the e-mail message promptly. Therefore, e-mail must not be used in a medical emergency. 

d. It is the responsibility of the sender to determine whether the intended recipient received the e-mail and when the recipient will respond. 

e. We cannot guarantee that electronic communications will be private. However, we will take reasonable steps to protect the confidentiality of the e-mail, or internet communication. However, is not liable for improper disclosure of confidential information not caused by its employee’s gross negligence, or wanton misconduct. 

f. If consent is given for the use of e-mail, it is the responsibility of the client to inform our staff of any type of information you do not want to be sent by e-mail. 

g. It is the responsibility of the client to protect their password or other means of access to email sent, or received, from our staff, to protect confidentiality. is not liable for breaches of confidentiality caused by the client. 

Any further use of e-mail initiated by the client that discusses their personal health information, constitutes informed consent to the foregoing. I understand that my consent to the use of e-mail may be withdrawn at any time by e- mail, or written communication, to and I have read this form carefully and understand the risks and responsibilities associated with the use of email. I agree to assume all risks associated with the use of email. 




By selecting this option, I agree to the terms above.


By selecting this option, I do not agree with the terms above and will discuss my concerns with the staff at

Question 11 of 11

Please read information below and answer question.  

Health Coaching Policy 

The health coaches at do not aim to diagnose or treat any sort of medical condition. We are not acting as primary care physicians at all and are not licensed to treat any medical condition. offers a wide range of functional lab tests and we are happy to provide health consulting with those who have ordered labs from us. Our lab test review is not meant to treat or diagnose any medical condition. 

Instead, we provide health coaching to help people improve their health. Our health coaching does not substitute for a Doctor – Patient relationship and we encourage you to work and consult with your primary care physician before beginning any lifestyle change. 

With any sort of lifestyle change or use of nutritional supplements, there are risks, and although the chances are slim, your health may get worse during this process. does not take legal responsibility for any changes in your health but will work with you to get the best health outcome. 

I understand that the health coaches at are not diagnosing or treating any medical condition I may have. I also understand that there are risks to any lifestyle change and to taking supplements. I accept full responsibility for my health condition and for any risks that may come with following the instructions set out by the health coaches. 


By selecting this option, I agree to the terms above.


By selecting this option, I do not agree with the terms above and will discuss my concerns with the staff at

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