First, is this still right?

You gave us these when you enquired. Change anything that has moved on.

Brought over from your enquiry. We are not going to ask you the same questions twice.

First name *

Please enter your first name.

Last name *

Please enter your last name.

Email *

Please enter a valid email address.

Phone or WhatsApp *

Please enter a number we can reach you on.

Date of birth *

Please enter your date of birth.

Sex at birth *

This decides which hormone markers apply.

Please choose one.

Where do you live? *

So we can point you to the nearest laboratory.

Please tell us where you are.

What brings you here?

You told us this already — confirm it, or add anything else. Your answers decide which markers Dr. Chacón needs, and nothing is added that you did not ask about.

Weight that will not shiftDespite diet or exercise Blood sugar, or I have been told pre-diabetesHigh readings, or a diagnosis Energy and fatigueTired in a way that rest does not fix HormonesLibido, muscle, mood, motivation Hormones, perimenopause or menopauseCycle changes, hot flushes, sleep, mood I just want my baseline read properlyNo particular complaint Something elseWe will read it ourselves rather than send you a panel

Please choose at least one.

Tell us in your own words

Your health

Be as complete as you can. This is what keeps the prescribing safe.

Medication

Everything you take, including doses *

Please answer, even if the answer is None.

I am already taking a GLP-1Ozempic, Wegovy, Mounjaro, Saxenda or compounded I am already on hormone therapyTestosterone, oestrogen, thyroid

History

Diagnosed conditions *

Please answer, even if the answer is None.

Surgeries

Allergies * No known allergies Yes, I have allergies

Please tell us whether you have any allergies.

Family history

Your cycle

Hormone results only mean something on the right day, so we need this to tell you when to go.

Are you still menstruating? *

Please choose one.

First day of your last period

We use this to tell you which day to attend the laboratory.

Do you already have bloodwork?

If it was taken in the last 90 days and covers what we need, you do not pay for it twice.

Yes, within the last 90 daysI can upload it Yes, but it is older than 90 daysWe will need it redone NoWe will tell you exactly what to ask for

Please choose one.

Upload your results

PDF or photo. You can add more than one.

Why 90 days. Beyond that a result no longer describes you now, and Dr. Chacón would be prescribing against a picture of someone you used to be.

What your answers point to

Based on what you told us, these are the markers Dr. Chacón needs in order to give you a reliable opinion.

We take no margin on any of this. You pay the laboratory what the laboratory charges. What you pay us for is the reading of it, and the plan that follows.

Before you send it

Three things, in plain language.

The doctor will plan from what I have written hereIf something changes, or you remember more later, tell us and we will update it This form is not a diagnosis and not a prescriptionA doctor decides, after seeing the results Cura Vida may hold these answers and my results as part of my medical recordShared only with the clinicians treating me

Please tick all three to continue.

A photo of your passport or cédula *

The doctor has to know who they are prescribing for. Held with your medical record and never shown to anyone outside the clinic.

Please add a photo of your ID.

Type your full name as a signature *

Please type your full name.

That is everything we need

One step left: the clinic fee. Everything after it is us.

Pay the clinic fee — $125

What happens after that

Dr. Chacón reviews your answers and confirms your panel.
We send you the laboratory request, and where to go near you.
You attend, fasting, on the morning we tell you.
Laura reads your results and Dr. Chacón decides.
You get the plan, whether or not it includes a prescription.

One company, three practices

Metabolic and longevity care

Online general practice

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