Breakthrough Application Form

1
Please confirm your Full Name* This field is required.
First Name
Last Name
2
Please confirm your Email Address* This field is required.Please ensure you use the same as given in the appointment booking
example@example.com
Confirm Email
3
Please confirm your Phone Number* This field is required.
Please enter a valid phone number.
4
Date of Birth* This field is required.
Date
Year
Month
Day
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What is your height?* This field is required.
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What is your weight?* This field is required.
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Please list all medications you are currently taking.* This field is required.
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What is your biggest health concern?* This field is required.
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What is your greatest desire for your health? * This field is required.
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What is your biggest obstacle right now preventing you from achieving your health goals?* This field is required.
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Briefly tell me about your current health status and what you are doing right now to solve your diabetes.* This field is required.
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How long have you been struggling with this health concern?* This field is required.
13
If someone asked me to make changes in my diet and lifestyle, take nutritional supplements or even begin tracking my food intake, I would…* This field is required.
embrace it, because I’m committed and know it’s what any serious health conscious person would do to solve this problem.
be a little intimidated, yet with a proven system, I would do it because I am serious about solving this problem.
Avoid it at all costs, because I’m not willing to make lifestyle changes or invest in my health.
14
Do you promise to show up for your scheduled appointment ON TIME and DISTRACTION FREE? Please confirm by typing, “Yes I will” in the box below.* This field is required.
15
Finally, on a scale from 1 to Bruce Lee, how awesome are you?* This field is required.
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