Online/in person training

1

Enter your name below* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

Phone NumberMay receive call or text

Area Code

Phone Number

4

Does becoming healthy interest you?* This field is required.

YESNO

5

Have you ever tried a diet before?* This field is required.

YESNO

6

Have you tried a exercise routine before?* This field is required.

YESNO

7

If yes to prior, please write down your experience with both diet and exercise Example: keto diet and cardio 4x a week

8

Do you have a goal you want to achieve?* This field is required.Example: lose weight / build muscle/ feel better

9

What does this goal mean to you?* This field is required.Why or anything specific

10

Are you taking any steps now to achieve that goal?* This field is required.

11

Do you have a medical issue that should be addressed?* This field is required.

12

Do you have any previous injuries or surgeries ?* This field is required.

13

If so do you have medical clearance?* This field is required.Select yes if you said no to the previous question

YESNO

14

By signing below you agree that you have answered all questions truthfully and willingly. You also acknowledge that with exercise there is always a chance of injury and will not hold (Dante Diaz) liable * This field is required.Side note: I will do my best to insure you don’t hurt yourself but will require communication

15

Any questions for me (Dante Diaz)

16

Where would be the best method of contact?* This field is required.Please leave form of contact below as well

17

Would you like to schedule a consultation Select a date and time best for you : date and time may subject to change