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Let's start with the basics.

We'll need some information like your mailing address so we know where to send your supplements, and will need to ask some health history questions to help better tailor your personalized supplement pack.

First Name*

Last Name*

Email*

Phone Number*

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City*

State*

Zipcode*

Please enter a number from 00000 to 99999.

Timezone*

Gender*

What's your date of birth?*

What's your date of birth?

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Are you interested in other treatments besides Smart Supplements?*

Check all that apply.

Hormone Optimization

Peptide Therapy

Weight Loss (Semaglutide & Tirzepatide)

Diagnostic Labs

Better Sex

Longevity & Anti-Aging

How did you hear about Blokes?*

Referral Source From Link*

Please provide the name or email address of whoever told you about Blokes.

What are your top goals?*

This helps us align your supplement solution with the ways you wish to improve your health. Check all that apply.

Sustainable Weight Loss

Overall Vitality

Increased Energy

Build Muscle Mass

Gut Health

Improve Anxiety & Mood

Reduce Inflammation & Pain

Skin Health

Hair Health

Sex Drive & Satisfaction

Cognitive Function

Better Sleep

Do you experience any of the following symptoms?*

Check all that apply.

Weight Gain

Loss of Muscle Mass

Depression

Lack of Energy

Low Motivation

Lack of Sexual Desire

Brain Fog

Anxiety

Hair Loss

Poor Sleep

Vaginal Dryness

Hot Flashes

Night Sweats

Heavy Menstruation

Joint Pain

Digestive Issues

None of These

Other

Other symptoms*

Please describe the other symptoms you're experiencing:

What are your current habits?

Do you walk daily?

Do you lift weights?

Do you count your calories?

Do you drink enough water daily?

Do you supplement your diet with protein?

Do you take antibiotics?

Do you do cardio?

Do you take supplements?

Supplements*

Please list the supplements you are currently taking:

What's your current height and weight?

We use this information to better assess which supplements are right for you.

Height (Feet)*

Please enter a number from 3 to 8.

Height (Inches)*

Please enter a number from 0 to 12.

What's your current weight?*

Do you have a history of drug and/or alcohol abuse?*

Yes

No

Are you currently breastfeeding?*

Yes

No

Are you currently taking any medications?*

Yes

No

Which medications are you currently taking?*

Please list all that apply.

Have you ever had an allergic reaction to any medications?*

Yes

No

Which medications have you had an allergic reaction to?*

Please list all that apply.

Have you ever had any of the following conditions?*

Select all that apply.

Type 1 Diabetes

Type 2 Diabetes

Seizures

Pancreatitis

Glaucoma

Gastroparesis

Cancer

Sleep Apnea

Low HDL-C

High Triglycerides

Prediabetes

High Blood Pressure

Heart Disease

Osteoarthritis

Polycystic Ovarian Syndrome (PCOS)

Non-Alcoholic Fatty Liver Disease

None of These

How long ago did you have cancer, and what type of cancer did you have?*

How long ago did you have cancer, and what type of cancer did you have?

Do you or your parents or siblings have a history of any of these conditions?*

Select all that apply.

Medullary Thyroid Cancer

Multiple Endocrine Neoplasia Type 2

None of These

You're almost there!

Here's what is coming up next:

1. Blood Draw & Consult

After you get your lab results back from your blood work, one of our clinicians will use our AI algorithm to create the optimal supplement formulation for your body.

2. Review Your Plan

You'll have a chance to review your treatment plan during a clinician visit, and you'll have the chance to adjust as desired. Your coach will go over how every supplement is personalized to your biomarkers.

3. Receive Smart Supplements

Your personalized supplement pack will be delivered straight to your door. You will have a chance to get your blood drawn every 6 months to track your progress and levels.

Pathway

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Start feeling your best again!

Review your order details below and get ready to gain exclusive access to our health program and therapies.

Smart Supplements Doctor Consult

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Subscriptions won't be charged until your consult

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By selecting "I agree to all and confirm" you confirm that the information you've provided is true.

In addition, you confirm that you have fully reviewed and agree to the Healthcare Informed Consent, the Authorization and Consent to Participate in Telemedicine/Telehealth Consultation, the HIPAA Notice of Privacy Practices, and the Self Payment Agreement. You confirm that you will allow Joi to sent you messages electronically. Such communications may include personal information, will not be encrypted, and may be viewed by others with access to your email and/or SMS/MMS text message accounts.

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