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Flouria Perimenopause Intake via form

Welcome to the Flouria intake. The purpose of this form is to better understand your symptoms and learn about your medical history. Based on this form you will be invited for the Flouria care path. It's important you fill out this form honestly, so we can offer you the right and high-quality care.
Completing the form takes about 10–15 minutes. It is sent in encrypted form, and your data will not be stored longer than necessary.

General information

Full name

Date of birth

What's your e-mail address?

What is the reason you are seeking help or support?

How would you describe your current situation, issues, or symptoms?

You can keep this short. As preparation for your first consultation, we will extensively ask about your symptoms.

Have you already discussed this with your (family) doctor?

Have you already discussed this with your (family) doctor?
A
B