First Name
*
Last Name
*
Email
*
Phone
*
Check this box if you prefer email and do not want a phone call from our office staff.
In order to help us determine the best options for your goals, we'll need a few more metrics from you.
Age
Height
Select one...
4 feet 01 inches
4 feet 02 inches
4 feet 03 inches
4 feet 04 inches
4 feet 05 inches
4 feet 06 inches
4 feet 07 inches
4 feet 08 inches
4 feet 09 inches
4 feet 10 inches
4 feet 11 inches
5 feet 00 inches
5 feet 01 inches
5 feet 02 inches
5 feet 03 inches
5 feet 04 inches
5 feet 05 inches
5 feet 06 inches
5 feet 07 inches
5 feet 08 inches
5 feet 09 inches
5 feet 10 inches
5 feet 11 inches
6 feet 00 inches
6 feet 01 inches
6 feet 02 inches
6 feet 03 inches
6 feet 04 inches
6 feet 05 inches
6 feet 06 inches
6 feet 07 inches
6 feet 08 inches
6 feet 09 inches
6 feet 10 inches
6 feet 11 inches
Weight
lbs
Please ask any questions you have or tell us anything else we should know.
How did you hear about us?
Select one...
Google/website
Ask Dr Ortiz
Chat
Eblast
Facebook
Facebook support group
Friend/word of mouth
Instagram
Lori's Blog
Pay per click
Physician referral
Private support group
RealSelf
The Ariel Center
Webinar series
Yelp
YouTube
Submit