Legacy Health Accelerator — Application
The Legacy Health Accelerator is a physician-guided 12-week metabolic optimization program. We review every application personally before confirming enrollment — this ensures the program is the right fit and that we can support you fully. Complete the form below and our team will be in touch within 48 hours.
SECTION 1 — ABOUT YOU
Full Name
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First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
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-
Month
-
Day
Year
Date
Gender
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Male
Female
Other
Where do you live? (City, State/Province, Country)
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Do you currently attend one of the Legacy Fitness Fit Body Boot Camp locations?
Yes, Roanoke
Yes, Daleville
Yes, Salem
No
Which program are you applying for?
Clinical Track ($2,500) — includes physician oversight, Tirzepatide, and full medical support
Foundation Track ($997) — includes labs, dietitian, coaching, and habit tracking. No medication. Option to upgrade mid-program if desired.
Not sure yet — I'd like guidance on which is right for me
SECTION 2 — YOUR HEALTH BACKGROUND
What is your primary health goal for the next 12 weeks?
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What are your top 3 health priorities right now?
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What are the biggest obstacles you’ve faced in achieving your health goals?
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Have you ever worked with a health coach or been part of a structured program before?
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Yes
No
If yes, what was your experience like?
Do you have any current medical conditions or diagnoses?
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Are you currently taking any medications or supplements? If yes, please list them.
*
Do you have any allergies (medication, food, environmental, etc.)?
*
SECTION 3 — COMMITMENT AND READINESS
Why do you feel now is the right time to join the Legacy Health Accelerator?
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How committed are you to making changes to your nutrition, activity, and lifestyle over the next 12 weeks?
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100% committed — I'm ready to go all in
Somewhat committed — I want to make changes but have some hesitations
Not sure — I need more information before deciding
Are there any potential barriers (work, family, travel, etc.) that could impact your ability to participate fully?
*
Is there anything else you’d like us to know about you or your goals?
SECTION 4 — SCHEDULING YOUR ONBOARDING CALL
If your application is approved, Josiah will reach out to schedule your onboarding call. This is where we walk through next steps, get you set up in our system, and confirm your start date. It typically takes 20–30 minutes.
What days of the week are generally best for your onboarding call?
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Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Other
What time of day works best for you?
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Morning
Afternoon
Evening
Other
If you are referred by a current member or provider, please share their name (optional):
Refund Policy — Legacy Health AcceleratorThe $2,500 program investment is due in full upon acceptance. Because lab testing and medication fulfillment are initiated on your behalf at enrollment, the following refund schedule applies:Cancellation before lab order is placed: Full refund less $150 administrative feeCancellation after lab order is placed, before medication ships: 50% refund ($1,250)Cancellation after medication has shipped: No refundNo refunds for voluntary discontinuation, side effects managed under physician care, or dissatisfaction with results
I have read and understand the refund policy above and confirm I am prepared to invest $2,500 upon acceptance
Submit Application
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