Purifi Elite Welcome Form

1

Name* This field is required.

First Name

Last Name

2

EmailNo spam ever. Used for EMR and secure messaging setup.

example@example.com

3

Phone NumberNo spam ever. This is for me, the provider, to contact you directly

Please enter a valid phone number.

4

What's Your Age?

5

How do you prefer to be contacted throughout your concierge experience?Choose all that apply

Phone call

Text message

Email

Secure client portal

Other

6

What is the #1 outcome you want to achieve with this program?Example: Energy, mental clarity, hormone balance, overall performance...

7

Which path are you most interested in exploring?

The Elite Reset- 90 day high impact intensive rest program

The Elite Membership - ongoing concierge optimization

I'm not sure- I would like to discuss both options

8

Have you worked with a private medical or coaching provider before?

Yes- I have invested in private care or coaching in the past

Not yet, but I am ready to explore this level of support

Prefer not to say

9

Where in Georgia are you located?

10

I deeply value your time. Some clients prefer to schedule dedicated time for updates. Others are too busy to schedule anything and prefer to send updates/questions as they come up — which we handle on the spot.

I prefer scheduled check-ins (dedicated 15–30 min blocks)

I prefer open, ongoing communication via text or message — handled in real-time

I’m open to a combination

11

When it comes to your health and performance, which describes your mindset right now?Once submitted, I’ll personally review and be in contact with your next step. Welcome to the beginning of operating at 100%.

I am done with average care- I want elite-level results

I am just starting to explore other options

I am not sure yet