Coaching Call Request Form

Please complete the following and return PRIOR to your call. Thank you!

Phone number for Dr. Conners to call*

Reason for Coaching Call Request*

**This is a 15-minute private, phone meeting. The fee for Coaching Calls is $135/15 minutes, to be paid prior to your call.

Check all that apply:

General follow-up to discuss recommended supplements, diet, etc.

New or changes in symptoms or findings (list below)

Discussion of labs and/or tests received (please email a PDF of labs to: labs@connersclinic.com)

Please list anything specific you would like to discuss or explain. *

I understand that Dr. Conners is NOT licensed to practice medicine in my state, DOES NOT practice medicine; DOES NOT prescribe, give, or administer any drug or medicine; DOES NOT offer or undertake to prevent, diagnose, correct, or treat any disease, illness, pain, wound, fracture, infirmity, deformity or defect; and DOES NOT offer to undertake to perform any form of surgery or hypnosis and that this coaching call is educational ONLY, does NOT constitute a tele-medicine visit, and I agree to seek medical help from my local practitioner. I agree to this coaching call on these terms and SUBMITTAL of this form constitutes my full agreement.

Signature in Agreement*