Private Member Application Form
This brief application ensures we’re a strong fit before scheduling your 1-on-1 Initial Assessment session. All care is private, personalized, and by invitation only.
1. Name
*
First Name
Last Name
2. Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
3. Email
*
example@example.com
4. Location (City + Zip Code)
*
Monmouth & Ocean counties in New Jersey only - Currently serve clients within 15 miles.*
5. Where would you prefer your session to take place?
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(Your home, your office, your gym, yacht, my home, etc.)
6. Preferred Days & Times for Your Private Session
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(Be as specific as you'd like – mornings, evenings on Saturdays, "Wednesdays at 2:30 PM", etc.)
7. What's your #1 concern, performance goal, or lifestyle need right now? And how do you envision our services supporting your goals?
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(ex., neck pain, fatigue, improving posture, chronic tightness, injury recovery, energy optimization)
8. On a scale of 1–10, how important is health & wellness to you? And are you currently investing in high-performance care (ex. trainer, specialist, private recovery)?
*
9. Have you worked with a chiropractor or body specialist before?
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Yes
No
10. What level of care are you seeking?
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One-time diagnostic + reset
Short-term relief (1–3 sessions)
Ongoing performance optimization
Not sure yet
11. How did you hear about Dr. Derek? Who referred you (if anyone)?
12. Final Question: Why do you believe you're a good fit for this?
*
13. By applying, you understand that:
*
14. Signature
*
Submit Your Application - Only 5 accepted per month.*
Submit Your Application - Only 5 accepted per month.*
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