1:1 Deep Dive Genetic Analysis Onboarding Form

First Name *

Last Name *

Email Address *

Sex at birth *

Male

Female

Street Address *

City *

Postal/Zip code *

State/Province *

Country *

Date of birth *

Phone *

If Mixed Ethnicity, which two? (Match with terminology used in prior question)

Did you order a DNA Kit through us? *

Yes

Raw Genetic Data

Upload Data Here

Important Labs & Bloodwork

Upload Here

What vitamins & supplements are you currently taking? Paste product names & PRODUCT LINKS below: *

Providing actual PRODUCT LINKS allows Dr. Panzner to give the best possible guidance versus just listing the supplement name! PLEASE follow this format...otherwise Dr. Panzner will have to use up your consult time to manually look up your supplements.

What prescription medication(s) are you currently taking? *

Do any diseases run in your family? *

Do you perform any type of exercise? If so, briefly explain the type and frequency *

How many times have you seen a doctor in the past year, for any health issue? Please specify which issue (don't count regular check-ups) *

How many times have you been hospitalized in the past year? Please specify the reason. *

How would you describe your diet in a few sentences? *

In a few sentences/paragraphs, please explain your overall health situation and goals. *

I confirm that I want to receive content from this company using any contact information I provide.