Apply to work with Dr. Belt!
Hi, I appreciate your interest in working with me and I'd love to hel you get healthy! Please fill out this short application so we can make sure we're a great fit. Thank you for taking the time to fill it out.
This form is not HIPAA compliant and does not establish a doctor-patient relationship with Dr. Belt. If you are a good fit, we will reach out to you via email so that we can move forward with your care!
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What is your name
What is your email address?
What is your phone number?
How old are you?
Where do you live?
Are you willing to make dietary changes, even if they are difficult?
Strongly disagree
Strongly agree
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Do you have any dietary restrictions you are unwilling to change?
Are you willing to move your body every day?
Strongly disagree
Strongly agree
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What is the current state of your general health
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What are your top 3 goals with your health? Or you can write a short description of your health issues.
How much time do you have to invest in your health?
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If we move ahead with your care, we'll reach out to you to schedule a Discovery Call. During this call, we can discuss which program is the best fit for you. Do you agree to this?
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How did you hear about Dr. Amber Belt?
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Thank you for taking the time to fill out the application!
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