New Customer Application
Customer Details:
Full Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
What sex were you assigned at birth?
Age Group?
<34
35 - 39
40 - 45
46 - 55
>56
Race/Ethnicity?
How did you hear about us?
*
Please Select
Facebook
Instagram
Pinterest
YouTube
Friend
Family/Referral
Other
Other? Please Specify
What are/is your current health struggle(s)?
Unwanted Weight Gain
Low Energy/Fatigue
Joint Pain/Arthritis
Fibroids
Peri/Post Menopause
(Pre)Diabetes
Poor Eating Habits
Other
Other? Please Specify
What’s your #1 goal for your health in the next 6 months?
On a scale from 1 to 5, how committed are you to investing in your health — financially, mentally, and emotionally? (1 = not committed, 5 = all in)
1 (not committed)
2 (somewhat committed)
3 (neutral)
4 (committed)
5 (all in)
What’s stopped you from reaching your health goals so far?
Are you willing to follow guidance, implement new habits, and be coachable?
Yes
No
Maybe
The full value of this program is $2,997, but because you were likely referred by someone or you're already in my network, you’re eligible for a special pilot rate of just $997 (with a payment plan available). If selected, are you prepared to invest at this rate to work with me privately?
Yes
No
Need More Info
Not Yet
Would you be willing to recommend this pilot program to someone else?
Yes
No
Please give reference of any two people whom you feel:
Rows
Full Name
Address
Contact Email
1
2
Submit
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