Pengtional Medicine

Patient Intake

Your intake, before we meet

Create your account, add a few photos, and tell us a little about how you're feeling. Your provider reviews everything personally — there's no automated diagnosis here.

Email Password — at least 8 characters

Already have an account?

A little about you

This goes straight to your provider for your visit.

You can dictate any answer — tap the microphone on a field, or use your phone keyboard’s mic.

Choose your program

Most people start with the Reset. You can step up to a larger program here — or add one later from your portal.

Your program fee is collected securely after you submit — your information is saved either way. Herbal formulas, supplements, and labs are billed separately, at cost. Your first visit is scheduled once your bloodwork is reviewed.

Full name

Date of birth

Sex — for lab ranges

Female Male

Occupation Phone Emergency contact — name & phone How did you hear about us? Primary health goals — what do you most want help with?

Medications & supplements

Each on its own line. Include the dose if you know it.

Anything else you'd like your provider to know?

Your photos

For the clearest read: natural daylight, and skip colored food or drink before your tongue photos.

Tongue — topneeded

Stick it out in good daylight.

Tongue — undersideneeded

Lift your tongue to the roof of your mouth and show the veins underneath.

Eyesoptional

Look at the camera, even light.

Faceoptional

Relaxed expression, even light.

I understand my selected program fee is collected securely after I submit, and that herbs, supplements, and labs are billed separately, at cost. I'm 18 or older and I agree to share these photos and details with my provider for my care. They are not used to make an automated diagnosis.

✓

Thank you — it's in.

Your intake and photos have been sent to your provider. You'll go over them together at your visit.

Pengtional Medicine™
Your information is private and used only for your care.