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Guided Fertility

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Hormone Evaluation Intake

Your information will be confidential and will only be shared with your consultant.

First Name

Last Name

Date of Birth

Phone

Email

Menstrual Patterns

What is Your Period Cycle Pattern

Regular

Irregular

How Long Have You Been Trying to Conceive?

How Often Do You Get Your Peiod

Every 21-27 Days

Every 28-30 days

Every 31-36 Days

Varies month-to-month (Irregular)

Mira Report

Upload Your Mira Report

Check Any of the Following Mentrual Symptoms

Heavy Flow

Bloating

Abdominal or Pelvic Cramping

Mood Swings / Irritability

Low Back Pain

Fatigue

Headache

Food Cravings

Please list questions or concens

Once you hit submit you can schedule your consult.

Guided Fertility™ encourages you to follow the medical advice of your physician. We are not in a position to diagnose, treat, or prescribe. Our services are intended for education, health promotion, and emotional support.

© 2024 by Guided Fertility, ™, LLC

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