Concierge Form

Name(Required)

First Last

Email(Required)

Enter Email Confirm Email

Is this request for you or someone else?(Required)

Someone else

What is the person's name?(Required)

What is your relationship to the person?(Required)

Please explain in 3-5 sentences what brought you here, what you are looking for or need help with.(Required)

Do you have any diagnoses or symptoms?(Required)

Yes

We ask for this information to better inform searches we might be doing for you but please only share if you are comfortable.

Please list any diagnoses.

Please list any symptoms.

I would like the WellBe Concierge Service to send me:(Required)

Medical/scientific research + summary/explanation

A doctor/practitioner/practice/other kind of health professional recommendation

A treatment or therapy center recommendation (acupuncture center, IV therapy center, meditation class, yoga studio)

Product recommendation (non-toxic shampoo, nail polish, etc.)

Product evaluation (ingredients and safety/toxicity of your products)

Retail place recommendation (restaurant, coffee shop, organic facial spa, etc.)

Online delivery service recommendation (meal delivery, baby food delivery, etc.)

Other

Select all that apply.

Address(Required)

City State / Province / Region ZIP / Postal Code Country

Please note the first field is city/town, no need to provide your street address

Medical/Scientific Research

Please list all research topics you would like returned to you.

Be as detailed as you can. Follow the example below:

The root causes of chronic Lyme Disease
Effective natural treatments for chronic Lyme Disease
The connection between SIBO and chronic Lyme Disease
The root causes of migraines
Effective natural treatments for migraines

Topic #1(Required)

How much research do you want for this topic?(Required)

Lite option - 3-5 pieces of research + WellBe explanation/summary - $29

Medium option - 6-10 pieces of research + WellBe explanation/summary - $49

Heavy option - 11-15 pieces of research + WellBe explanation/summary - $69

I no longer want this.

Is there another topic you'd like research on?(Required)

Yes

Topic #2(Required)

How much research do you want for this topic?(Required)

Lite research topic + WellBe explanation/summary (3-5 pieces of research sent back) - $29

Medium research topic + WellBe explanation/summary (6-10 pieces of research sent back) - $49

Heavy research topic + WellBe explanation/summary (11-15 pieces of research sent back) - $69

Is there another topic you'd like research on?(Required)

Yes

Topic #3(Required)

How much research do you want for this topic?(Required)

Lite option - 3-5 pieces of research + WellBe explanation/summary - $29

Medium option - 6-10 pieces of research + WellBe explanation/summary - $49

Heavy option - 11-15 pieces of research + WellBe explanation/summary - $69

Is there another topic you'd like research on?(Required)

Yes

Topic #4(Required)

How much research do you want for this topic?(Required)

Lite option - 3-5 pieces of research + WellBe explanation/summary - $29

Medium option - 6-10 pieces of research + WellBe explanation/summary - $49

Heavy option - 11-15 pieces of research + WellBe explanation/summary - $69

Is there another topic you'd like research on?(Required)

Yes

Topic #5(Required)

How much research do you want for this topic?(Required)

Lite option - 3-5 pieces of research + WellBe explanation/summary - $29

Medium option - 6-10 pieces of research + WellBe explanation/summary - $49

Heavy option - 11-15 pieces of research + WellBe explanation/summary - $69

Is there another topic you'd like research on?(Required)

Yes

Topic #6(Required)

How much research do you want for this topic?(Required)

Lite option - 3-5 pieces of research + WellBe explanation/summary - $29

Medium option - 6-10 pieces of research + WellBe explanation/summary - $49

Heavy option - 11-15 pieces of research + WellBe explanation/summary - $69

Is there another topic you'd like research on?(Required)

Yes

Topic #7(Required)

How much research do you want for this topic?(Required)

Lite research topic + WellBe explanation/summary (3-5 pieces of research sent back) - $29

Medium research topic + WellBe explanation/summary (6-10 pieces of research sent back) - $49

Heavy research topic + WellBe explanation/summary (11-15 pieces of research sent back) - $69

Is there another topic you'd like research on?(Required)

Yes

Topic #8(Required)

How much research do you want for this topic?(Required)

Lite option - 3-5 pieces of research + WellBe explanation/summary - $29

Medium option - 6-10 pieces of research + WellBe explanation/summary - $49

Heavy option - 11-15 pieces of research + WellBe explanation/summary - $69

Doctor or Health Professional Recommendation

What type of doctor or health professional recommendation would you like?(Required)

For example: Holistic psychiatrist, gut health-focused MD, integrative cancer doctor, functionally-trained nutritionist

How many recommendations do you want?(Required)

Lite option: 3-5 names with basic details like website, license type, city/state, specialty - $49

Medium option: 6-10 names with basic details like website, license type, city/state, specialty - $69

Heavy option: 11-15 names with basic details like website, license type, city/state, specialty - $99

I no longer want this.

If we do not find suitable options in your town, please let us know how far you are willing to travel outside of your town, please use miles or hours (for example, 50 miles or 1 hour drive).(Required)

How do you feel about seeing a health professional virtually?(Required)

I prefer to see someone virtually

I prefer to see someone in person but I'm open to virtual

I don't want to see someone virtually

Would you like to know more details to help you make a decision about which health professional to choose?(Required)

Yes - $49

We can call each one and find out if they take your insurance and/or your FSA/HSA + how they do billing + whether they are taking new patients + when the next appt is + whether they see patients virtually + pricing + if they have experience/expertise with your particular set of symptoms and/or condition.

Would you like to know more details to help you make a decision about which health professional to choose?(Required)

Yes - $89

Would you like to know more details to help you make a decision about which health professional to choose?(Required)

Yes - $149

Symptoms and/or conditions you want them to have experience/expertise in(Required)

If you are only willing to see one provider type (MD, DO, ND, NP), please list below. If you are willing to see many different kinds of providers, leave this blank.

If you want us to ask the health professional's office if they take your insurance or FSA/HSA, please indicate the type of insurance you have below and/or if you have an FSA or HSA you can use to pay for treatment.

If there is anything else you want us to find out when we call the health professional's office, please list it below.

Treatment or Therapy Center Recommendation

What type of treatment/therapy center recommendation would you like?(Required)

For example: Acupuncture center, IV therapy center, Infrared Sauna therapy center, meditation studio, yoga studio

How many recommendations would you like?(Required)

Lite option - 3-5 places with basic details like website, type, city/state, specialty - $39

Medium option - 6-10 places with basic details like website, type, city/state, specialty - $69

Heavy option - 11-15 places with basic details like website, type, city/state, specialty - $99

I no longer want this.

Would you like us to get more details about these recommendations?(Required)

Yes - $49

We will call each place/center to find out whether they take your insurance and/or your FSA/HSA if applicable + pricing/how they do billing + what the availability is/hours + whether the treatment or therapy is offered virtually + address or addresses if they have multiple locations + symptoms and/or condition they have experience with/expertise in if applicable

Would you like us to get more details about these recommendations?(Required)

Yes - $89

Would you like us to get more details about these recommendations?(Required)

Yes - $149

Please explain any relevant details that would help us narrow our search including but not limited to:

Symptoms and/or conditions you want them to have experience with/expertise in.(Required)

If you are only willing to see one provider type or do one kind of therapy, please list below. If you are willing to see many different kinds of providers or do different kinds of threrapies, leave this blank.

If you want us to ask the center if they take your insurance or your FSA/HSA, please indicate the type of insurance you have below and/or if you have an FSA or HSA you can use to pay for treatment.

If there's anything else you want us to find out when we call the center, please list it below.

Product Recommendation

What type of product recommendation would you like?(Required)

For example: Non-toxic Shampoo, nail polish, clean coffee brands, etc.

How many recommendations do you want?(Required)

Lite option - 3-5 options with basic details like website with link to purchase, applicable ratings from third party organizations, other info like gluten-free, phthalate-free, etc. - $29

Medium option - 6-10 options with basic details like website with link to purchase, applicable ratings from third party organizations, other info like gluten-free, phthalate-free, etc. - $39

Heavy option - 11-15 options with basic details like website with link to purchase, applicable ratings from third party organizations, other info like gluten-free, phthalate-free, etc. - $49

I no longer want this.

Are there any specific ingredients the product should not have?(Required)

Yes - $9

Example: It cannot contain vitamin E or gluten or any form of corn because of allergy. Our team will comb through ingredients lists.

Would you like us to only return results with specific criteria?(Required)

Yes - $19

Example: It cannot contain vitamin E or gluten or any form of corn because of allergy. Our team will comb through ingredients lists.

Are there any specific ingredients the product should not have?(Required)

Yes - $14

Example: It cannot contain vitamin E or gluten or any form of corn because of allergy. Our team will comb through ingredients lists.

Please explain any relevant details that would help us narrow our recommendation search including but not limited to:

If you have a max you are willing to spend on this product, please list it below.

Retailer/seller/shipping preference, if none, leave this blank.

Example: Preference for Amazon, or for Amazon Prime, or product must ship to/be sold in Canada

Are there any specific ingredients the product should not have?

Example: It cannot contain vitamin E or gluten or any form of corn because of allergy. Our team will comb through ingredients lists.

Certifications

Example: Must be USDA organic or must be third-party-certified

Container/Material

Example: Must come in glass (not plastic) or be BPA-free plastic

If there is anything else that would help us in our recommendation search, please list it here.

Product Evaluation

Please list below the brands and product names you would like us to evaluate for toxicity(Required)

Please separate the brand name from the product name with a comma. Follow this example: Supergoop!, Unseen Sunscreen SPF 40

If you prefer, you can upload a clear photo of the front and back of your product or products.(Required)

Yes, I would like to upload images of my products.

No, I am not going to upload images of my products.

Upload your product images.

Drop files here or

Accepted file types: jpg, png, gif, Max. file size: 50 MB, Max. files: 24.

How many products would you like us to evaluate for you?(Required)

Lite - 1-3 products - $29

Medium - 4-6 products - $39

Heavy - 7-9 products - $49

Ultra heavy - 10-12 - $59

I no longer want this.

Retail Place Recommendation

What type of place (store, coffee shop, restaurant, spa, etc.) recommendation would you like?(Required)

Location: Zip code where you would like this place to be ideally. Please also indicate how far away from your address or zip code you are willing to travel if we cannot find what you are looking for in your zip code. If you want a recommendation within a few blocks of a certain address, please write the address below.(Required)

How many recommendations would you like?(Required)

Lite - 3-5 options with basic details like website link, address, and other relevant info like gluten-free, organic, vegan, etc. - $29

Medium - 6-10 options with basic details like website link, address, and other relevant info like gluten-free, organic, vegan, etc. - $39

Heavy - 11-15 options with basic details like website link, address, and other relevant info like gluten-free, organic, vegan, etc. - $49

I no longer want this.

Would you like us to find out any additional information?

Yes - $19

For example ) Search for a specific address to see how many blocks away/how long the walk or drive is from you or see if a restaurant uses a specific ingredient you're trying to avoid like vegetable oils, or whether a restaurant claiming to be organic is actually USDA organic certified - finding these things out often require us calling the location to get more information.

Would you like us to find out any additional information?

Yes - $29

Would you like us to find out any additional information?

Yes - $39

Please explain any relevant details that would help us narrow our search including but not limited to:

If you have a price preference, please use this: $ inexpensive, $$ moderate, $$$ expensive, $$$$ very expensive. If you'd like to see all the options at every price level, leave this blank.

Any particular qualities you're looking for in this place?

For example, "gluten-free" or "vegan"

Anything else that would help us in our recommendation search?

Online Service Recommendation

What type of online service (meal delivery, baby food delivery, etc.) recommendation would you like?(Required)

How many recommendations would you like?(Required)

Lite - 3-5 options with basic details like website link, other info like gluten-free, organic, vegan, etc. - $29

Medium - 6-10 options with basic details like website link, other info like gluten-free, organic, vegan, etc. - $39

Heavy - 11-15 options with basic details like website link, other info like gluten-free, organic, vegan, etc. - $49

I no longer want this.

Would you like a specific shipping location or ingredient researched?(Required)

Yes - $19

Search for a specific address i.e. “must ship to Puerto Rico” to only return results that are available to you if you’re in Puerto Rico and/or a search for a specific ingredient used i.e. must not use vegetable oils, and/or search for services that are USDA organic certified - these kinds of requests usually require our team to call or email the company to get more information.

Would you like a specific shipping location or ingredient researched?(Required)

Yes - $29

Would you like a specific shipping location or ingredient researched?(Required)

Yes - $39

Please explain any relevant details that would help us narrow our search including but not limited to:

If you have a max you are willing to spend on this service, please list it below.

Do you have a shipping requirement?

For example: "Must ship to or be sold in Canada"

Any ingredients this product cannot contain?

For example: "Cannot contain any corn or corn derivative because of allergy"

Any certifications that are important to you?

For example, must be USDA organic or must be third-party-certified

Any container type very important to you?

For example: Must come in glass (not plastic)

Is there anything else that would help us in our recommendation search?

Other

We'd have to know your specific request if it does not fall into any of these categories before we can give you an estimated price. Please describe what you need help with below and we will get back to you with pricing before we begin work.(Required)

This field is hidden when viewing the form

Book a Call

Please let us know what type of call you would like.(Required)

30 min clarity call with Adrienne to determine what you need help with and how we can help

I no longer want this.

Once your order is confirmed, a calendar link will be sent to you by email to schedule this call.

Purchase Details

If we cannot return anything in your search, we will refund you the entire cost. If we can only return less than expected (i.e. you ask for “heavy” results on a doctor but we could only find “lite” we have still done extra digging to try to find more for you however in this case we will partially refund you to the next level down i.e. if you selected “heavy” but we couldn’t return 11 or more results, we’ll charge you for “medium”. If you selected “medium” but we couldn’t return 6 or more results, we’ll charge you for “lite”.

I consent that WellBe is providing me with information and recommendations based on their research skills, knowledge, and expertise of the holistic health and wellness market. WellBe has no affiliation with any of the products, organizations and individuals returned in the search results. My decision to purchase any products and services that WellBe recommends is mine alone. I understand that WellBe is not providing medical advice and makes no promises as far as health outcomes from using any of the products and services returned in your results. WellBe holds no responsibility for the effectiveness and experience of any products or services I decide to purchase.(Required)

I consent to these terms.

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