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

I’m not sure what I would like WellBe to send me, I’d like to talk to someone on the phone to figure it out.

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

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

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)