Physiomed Community App + Free Program Application Form

1

Name & Clinic* This field is required.Please insert your name and clinic location.

First Name

Last Name

Clinic Location

2

What is your best E-mail?* This field is required.This will be used to send you your unique link to join the free program.

example@example.com

3

Phone Number* This field is required.

Please enter a valid phone number.

4

What are your dream health, wellness & fitness goals? Please describe your goals for the next 3 months, 6 months & 2 years.* This field is required.Please be specific as this helps us give you additional resources in order to help you further; ie: please don't just state that you want to "be healthy".

5

Two 1 on 1 Zoom calls are the core of our free community: A 45 Min Blueprint Call 📘 (occurs at a time of your choosing in 3-10 days from now), and a 15 Min Results Call 🎯 (occurs in 6-8 weeks at a time of your choosing). These calls give you custom advice for free and allow us to write down your results from the free community after you've been in it for 6-8 weeks. It is the only thing we ask for in return. Confirming allows us to organize & dedicate time to helping every patient sincerely, as these calls are the backbone that keep our community inclusive & beneficial and its access free. Do you agree to schedule both calls within 24hrs of submitting this form? * This field is required.(The booking link will redirect after submitting this form; it will also be emailed directly to you after submission. You will have 24 hours to schedule these calls otherwise accounts in the program get auto-removed)

Yes, I understand. These calls are to help ME get amazing results. I will schedule times I can attend with no distractions, out of courtesy to the professionals here helping me completely for free.

Yes, I understand the above. I'd love earlier seating for my Blueprint call in order to receive my custom document & 1 on 1 personalized help as fast as possible!

Yes, I understand the above. My total health goals are currently my top priority. I am interested/curious in applying for the Paid Programs offered by Physiomed Nutrition when they are available. I request to get notified when openings arise in case I want to consider applying .