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New Patient Application

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Apply to be a New Patient

First Name

Last Name

Email

What hormone symptoms or challenges are you seeking help with?

Have you seen any doctors or tried any treatments up to this point? If so, what have you tried?

How committed are you in making the recommended changes?

Have you read through the website, especially the "Let's Work Together" page to familiarize yourself with the process of working together?

Do you have any questions right now?

Thank you for submitting an application to work with The Hormone Doctor. We have received it and will contact you to let you know either way. Thank you!

This website offers health, wellness, nutritional, and fitness information and is provided for informational purposes only. The information is not intended to substitute the advice provided by your physician or other healthcare professional. This information does not replace professional medical advice, diagnosis, or treatment, and should not be relied on as a substitute for the above. Always speak with your physician or other healthcare professional before starting any new medication or nutritional, herbal or homeopathic supplement, or using any treatment for a health concern. If you suspect or know that you have a medical problem, contact your physician or health care provider immediately. Do not disregard professional medical advice or delay in seeking professional advice because of something that you have read on this web site. The use of any information provided on this website is solely at your own risk. Nothing stated or posted on this website or available through any services offered by Dr. Jillian Smithers, N.M.D. and AZ Hormone Specialists, LLC, are intended to be, and must not be taken to be, the practice of medicine. Information provided on this web site does not create a doctor-patient relationship between you and Dr. Jillian Smithers. Information and statements regarding dietary supplements have not been evaluated by the Food and Drug Administration and are not intended to diagnose, treat, cure, or prevent any disease.

©2021 by Dr. Jillian Smithers, NMD and AZ Hormone Specialists, LLC.