vida
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vida clínica virtual

join the vida clínica virtual waitlist 🤍

physician-led evaluation + treatment for premenstrual disorders, hormonal disorders + perimenopause.

first, let's see if we're the right fit.

this form helps us understand what you're experiencing, what kind of support you're looking for + whether vida clínica virtual may be the right place for your care.

completing this form does not establish a physician-patient relationship and is not a medical evaluation or consultation.

once we review your responses, if it looks like vida clínica virtual may be a good fit, we'll share next steps as appointments become available in your location.

and if we're not the right fit? we won't leave you wondering what to do next. we'll do our best to provide general guidance about the type of healthcare professional or service that may be more appropriate for what you're experiencing.

please don't include detailed medical records, medication lists or urgent medical concerns in this form.

ready? tell us a little about you + what's been going on. 🤍

01

about you

where do you currently live?

where you live helps us understand where there is a need for care + whether vida clínica virtual may be able to provide clinical services in your location.

preferred language

where are you currently in your reproductive journey?

select all that apply.

when was the first day of your last menstrual period?

02

your symptoms

what symptoms are you experiencing?

select all that apply.

mood + emotional

cognitive

sleep + energy

physical

appetite + digestion

menstrual cycle

03

what feels hardest right now?

we want to understand what you're experiencing—not just which symptoms you check on a list.

what are the biggest problems your symptoms are causing in your life right now?

select all that apply.

if you could change ONE thing about how these symptoms affect your life, what would it be?

optional.

in your own words, what made you look for help now?

optional.

04

your cycle + symptoms

do you notice your symptoms changing depending on where you are in your menstrual cycle?

when do you tend to feel your worst?

how much do your symptoms interfere with your everyday life?

where do you notice the biggest impact?

select all that apply.

05

your experience getting care

have you previously talked with a healthcare professional about these symptoms?

approximately how long have you been looking for answers or treatment for these symptoms?

what has been the most frustrating part of trying to get help?

optional.

06

what are you looking for?

what would you most want from vida clínica virtual?

select all that apply.

07

care preferences

when would you ideally like to be seen?

would you be comfortable with a cash-pay practice that does not bill insurance directly?

08

how did you find vida?

how did you hear about vida?

select all that apply.

anything else you'd like us to know about what you're looking for from vida?

optional.

important: submitting this form or joining the waitlist does not establish a physician-patient relationship, constitute medical advice, or guarantee that vida clínica virtual will be able to provide care. this form is not monitored for urgent or emergency medical concerns. if you are experiencing an emergency, seek immediate medical care or contact the appropriate emergency services in your location.