First, where do you live?

We see patients by video in 33 states. Your state decides whether we can care for you.

Your information is encrypted and never shared

We can't see you in yet

Our providers are licensed in 33 states, and we are adding more. We are sorry we can't help you today.

States we serve

Choose a time for your first visit

Initial Medical Visit · 20 minutes · video visit from home · $99

Pick a day

Available times · Pacific

Free cancellation up to 24 hours before your visit

Tell us who you are

Your information is encrypted and never shared

Review and pay

Initial Medical Visit · video

Due today$99.00

Card details

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You're booked

One more step before your visit

Your health questionnaire. About 10 minutes.

Save anytime and finish later from the link in your email.

Welcome

Questionnaire progress

0 of 4 sections complete

About youStart →

Your health historyNot started

Your symptomsNot started

Consent & signatureNot started

Recent labsoptionalAdd →

Your answers save automatically after each section. You can close this page and come back anytime.

On a shared computer? Tap Start over when you finish. It removes your saved progress link from this browser.

Section 1 of 4

About you

Your home address for your medical record.

Street addressPlease enter your street address

Apt / unit (optional)

CityPlease enter your city

StatePlease choose a state

ZIPPlease enter a 5-digit ZIP

Section 2 of 4

Your health history

This helps your doctor understand the full picture.

Which best describes your menstrual cycle in the past year? Please choose one

Are you currently on hormone replacement therapy?

Please choose Yes or No

Are you currently on birth control?

Please choose Yes or No

Have you had a hysterectomy?

Please choose Yes or No

Have you had your ovaries removed (oophorectomy)?

Please choose Yes or No

Weight (lbs)

Height (ft)

(in)

Please enter your weight and height

Medications you take (add each one)

Allergies (add each one)

Your medical history. Check what applies to you.

Any family history of the following?

Section 3 of 4

Your symptoms

Rate how much each affects you these days.

0 = not at all5 = severe

Other symptoms (optional)

Recent labs

Optional. If you have lab results from the past year, add them here. Our care team reviews them before your visit.

Choose filesPDF or a clear photo. Up to 10 files, 10 MB each.

Not sure what to send? Hormone panels, thyroid, lipids, or a recent annual physical are all helpful. Skip this if you have nothing handy.

Section 4 of 4

Consent & signature

The last step. Please review and sign.

I authorize Golden Leaf Health to contact me about my care and follow-up by text message, email, or phone call. Message and data rates may apply. I consent to receive care through telemedicine, and I understand its benefits and limitations. I have read and accept the cancellation policy.

Please check each box to continue

Type your full legal name as your signature Please type your full legal name