Make the Most of Your Free Phone Consult or Intro Session

We’re excited to connect with you! Before our meeting, please take a moment to complete this optional 2-minute check-in. It’s quick, easy, and private — and it’s the best way to help us personalize our conversation and focus on what matters most to you.

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We're excited to connect with you!

During your upcoming appointment, we’ll go over a few simple questions to get a snapshot of your health and to focus on what matters most to you.

To help us personalize your experience, please take a moment to complete this optional 2-minute check-in. It’s quick, easy, and the very best way to get a head start!

First, Let's Get to Know You!

which Insurance About

Name *

First

Last

Email Address *

Phone Number *

Date of Birth *

How did you find OsteoStrong?

• Facebook/Instagram
• Google/Internet search
• TickTock/Twitter
• Friend or Family

Would you like our help determining if your insurance may help cover your OsteoStrong sessions? *

• Yes
• No

Insurance Information

Insurance Information – if you do not qualify or do not wish to provide information at this time, check NO to question above.

This information is required to help us validate your insurance option and be prepared for your first visit!

What insurance process(es) do you intend to use? You may choose more than one. *

• Medical Letter of Necessity? You work with your doctor to get reimbursement or tax write-off
• Medicare? You work with your insurance (CPT code S9970); you submit to insurance
• FSA/HSA Card (debit card – be sure to bring your card to your first visit)
• FSA/HSA Card (submit to provider – ask us to provide a receipt for your submission}
• BCBS – Active&Fit / Silver&Fit- contact your provider to ensure coverage and to activate
• Optum / OnePass / RenewActive / Aptiv

Please select the first letter of your membership number *

• A
• B
• G
• P
• S

Enter the company you work for: *

Who is the agent providing this coverage *

Enter the full membership number: *

Please provide your full address including zip code: *

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Height (feet) *

Height (inches)

Height (quarters of an inch)

Weight *

Do you have family members with the same insurance that will benefit from Osteostrong? Please list.

Wellness Questions

Please answer the following questions to help us prepare for your session

OsteoStrong can help with all of the following — which are most important to you? (check all that apply) *

• Increase Bone Density & Reduce Fracture Risk
• Build Strength & Improve Physical Perfomance
• Boost Daily Energy & Vitality
• Reduce or Eliminate Chromic Pain
• Strentgthen Immune System
• Improve Posture and Balance
• Support Healthy Blood Sugar Levels

Do you regularly feel pain in any of these areas? (check all that apply) *

• Lower Back
• Mid or Upper Back
• Neck
• Hips
• Knees/Ankles
• Shoulders/Elbows/Wrists

Tell Us About Your Goals & Challenge

We’d love to understand what you’re hoping to improve and what success would look like for you.

1. What would you love to improve in your health and daily life?

Examples: “Increase bone density,” “Avoid falls,” “Walk without hip pain,” “Have more energy.”

2. What’s something you miss doing — and what’s been getting in the way?

Examples: “I miss hiking but don’t want to fall and break a bone,” “Gardening hurts my back after 10 minutes.” “I don’t have the energy to keep up with my grandkids.”

3. How much discomfort or pain are you feeling right now?

Selected Value: 1

(1 = mild, 10 = severe)

4. What have you already tried to improve your health — and how did it go?

Examples: “I tried medication, but I didn’t like the side-effects.” “Physical therapy helped a little but the pain came back.”

5. How motivated do you feel to take the next step?

Selected Value: 1

1 = I’m just exploring, 10 = I’m all in!

You're Almost Done!

We’d love to understand what you’re hoping to improve and what success would look like for you.

Anything else you'd like us to know?

Feel free to share any questions or extra details — anything you think might help us better prepare for your appointment.

We would also like to send you our monthly newsletter with helpful wellness tips, inspiring member stories, and special offers.

• Yes! I’d like to stay in the loop!

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• I consent to having this website store my submitted information so OsteoStrong can better prepare for my appointment.

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Thank you for taking the time to share with us.

We look forward to speaking with you – and supporting your health and wellness every step of the way.

Learn more at: https://osteoststrongmn.com.