Request Your Free Custom Health Advice—No Obligation
First Name
*
Last Name
*
Date of birth
Email
*
Phone
*
Occupation
City
*
Health conditions/concerns
*
What symptoms are affecting your life the most?
*
What symptoms are affecting your life the most?
Fatigue / Low energy
Brain fog / Memory issues / Poor focus
Low immunity (Frequent colds, Slow recovery)
Respiratory symptoms (Shortness of breath, Chronic cough)
Stress / Anxiety / Low mood / Mood swings / Irritability
Pain (Back pain, Joint pain, Muscle aches)
Sleep problems (Insomnia, Poor sleep quality)
Headaches / Migraines
Digestive issues (Bloating, IBS, Constipation, Reflux)
Weight gain / Difficulty losing weight
Skin issues (Eczema, Acne, Rashes)
Hormonal imbalances (PMS, Perimenopause, Thyroid)
Allergies / Hayfever / Food sensitivities
High blood pressure / Cardiovascular symptoms
No elements found. Consider changing the search query.
List is empty.
When did your symptoms or conditions begin?
What therapies have you tried
Are you pregnant?
Yes
No
Not applicable
Do you have pacemaker?
Yes
No
Any medical conditions or injuries we should be aware of?
Which services are you most interested in? (Check all that apply):
Functional Medicine Consultation
Treatment(single session)
Personalised program combining both options above
No elements found. Consider changing the search query.
List is empty.
Are there any therapies or approaches you’re not comfortable with or would prefer to avoid?
If your health improved significantly, what activities or experiences would you love to enjoy again?
Have more energy and feel like myself again
Reduce or eliminate daily pain
Sleep better and wake up refreshed
Get back to work or hobbies I enjoy
Rebuild my immune system and resilience
Be more present for family and loved ones
Enjoy travel or social activities again
Restore appetite, digestion, or weight balance
Feel confident in my body and health choices
Regain a sense of calm, confidence, and hope
On a scale of 1 – 10, how committed are you to making lifestyle changes to improve your health?
When would you like to begin?
Immediately
Within 2 weeks
1–2 months from now
I’m in no rush
No elements found. Consider changing the search query.
List is empty.
Would you have a budget in mind?
Under $500
$500 - $1,000
$1,000 - $3,000
Cost is not an issue
No elements found. Consider changing the search query.
List is empty.
How did you hear about us?
Feedback on this form or anything else you would like us to know
I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.
Submit
Jump Start with Our Most Popular Consultation
2025 Brilin LTD,
brilin.co.nz
All Rights Reserved