Purifi Elite Evaluation

1

Name* This field is required.

First Name

Last Name

2

What's Your Age?

3

What City In Georgia Do You Live?

4

What are your main goals for joining this program?

Boost energy and stamina

Improve libido or sexual health

Build lean muscle / lose fat

Improve sleep and mental clarity

Address hormonal imbalances

Longevity and aging optimization

Other

5

Have you been on hormone or TRT therapy before?

Yes, currently

Yes, in the past

No, this would be my first time

6

Are you currently taking any medications or supplements?

8

This program is $2,499/month and includes full concierge care. Are you financially ready to invest in your health at this level?* This field is required.

Yes, I’m ready to invest now

I need to review with my partner or budget

No, this price isn’t within reach

9

How soon are you looking to start?

Immediately

Within 2 weeks

Within 30 days

Just exploring for now

10

What best describes your level of commitment to change?

100% committed and ready

Curious but not sure yet

Just researching