PROGRAM QUESTIONAIRRE
Transformation Begins Here.
Step 1) Fill out this form - This info will help us determine if you qualify for this VIP Doctor Supervised program.
Name
*
First Name
Last Name
Email
*
example@example.com
Cell Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Male
Female
Age
Height
Current Weight
6 Month Target Weight
Overall Target Weight
Average Energy Level
Always fatigued
1
2
3
4
5
6
7
8
9
On Fire 🔥🔥🔥
10
1 is Always fatigued, 10 is On Fire 🔥🔥🔥
Current Diagnosed Conditions/Diseases
Current Medications
Current Supplements
What is the #1 reason WHY you want to lose weight & gain health?
What is it worth to you to Jumpstart your weight loss and reach your 6 month target weight?
Why would you be a great addition as a client to our program?
Why should we work with you as a client?
How did you hear about our program?
Who referred you?
Next Steps...
Hit submit, then schedule a 30 min zoom call with Dr. Koepfler - follow the steps on the next page - We're excited to help you jumpstart your metabolism and health transformation!
Submit
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