Request edit access
Apply to work 1:1 with Dr. Meléndez
You are applying to work with Dr. Meléndez within her high support, 1:1 Functional Wellness Journey Package.
Sign in to Google to save your progress. Learn more
Email
Name
Gender
Clear selection
State you live in
Who you were referred by or how you found Dr.Meléndez
Have you worked with a Functional Medicine Practitioner Before?
Why are you interested in working with Dr. Meléndez?

Please describe your top health concerns that you want to address while working with Dr. Meléndez
What's your current motivation to improve your health and wellness, including your willingness to make diet and lifestyle modifications?
How much do you currently invest per month into your longterm health and wellness? 
(This would include supplements, vitamins, herbs, gym memberships, sauna sessions, chiropractic care, etc.)
Do you have the resources to invest $400+ per month for a minimum of 8 months into your health and wellness?
Clear selection
Are you at a place in your life where you can commit 8-9 months minimum to uncovering the root causes behind your current health concerns and create sustainable wellness practices for your longterm health? *

Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report