Name *

First Name

Last Name

Phone *

(###)

###

####

Check all that apply *

Alcohol use

Anxiety

Caffeine Use

Constipation

Dairy Consumption

Depression

Diarrhea

Dry, Itchy Scalp

Dry Mouth

Fatigue

GERD | Heartburn

Hair Loss

Hashimoto's

Hyperthyroidism

Insomnia

Irritability

Low Energy

Menopausal Symptoms

Skin Inflammation

Smoking | Vaping

Vegetarian Diet

Weight Gain

Weight Loss

Agreement *

By filling out and signing this application, you give Dr. Sally LaMont permission to review this information and share information surrounding your case, without revealing your name or other personal identifying factors, to participants in the Dr. Sally’s Stay Hungry Facebook Group. As a case study participant, you will receive general information about certain symptoms and possible food related triggers. No medical advice is given or inferred during the case study and you are advised to seek medical attention for any, and all, health concerns. Furthermore, you are voluntarily participating in this case study and, you agree to indemnify and hold harmless Dr. Sally LaMont against any and all claims, suits or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by me or anyone on my behalf, including attorney's fees and any related costs, if litigation arises pursuant to any claims made by me or by anyone else acting on my behalf.

Please check here to denote that you have read and agreed to the above statements.