New Patient Registration Form

Client Form

Are you ready to make a lifestyle change? If you truly are committed to making a change in your life and ready to invest in yourself please fill out this form to help me get to know you and understand where you currently are.
Name

First NameMiddle NameLast Name
Instagram handle
Gender
Height (inches)
Date of Birth
Weight (pounds)
Email
example@example.com
Contact Number:

Area CodePhone Number
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Did someone refer you to me? If so who?

First NameLast Name
Which plan are you interested in?
Goals
Out of the above answers other than your main goal, is there anything else you want to work on?
Describe your goals:
What is your current exercise routine? If you have an Apple Watch how many steps a day? (Cardio, resistance training, time/times per week)
What does your current diet look like? (Sending a food log would be helpful!)
Do you have any previous injuries or surgeries?
Do you have any exercise limitations I should be aware of?
Please describe an average day for you; current occupation/activity level
Realistically, how many days a week would you be able to fit in a 45-60 min workout?
Are you looking for a home or gym based plan?
Taking any medications, currently?
If yes, please list it here
This product requires for you to download the app trainerize to work with me, do you have apple, Samsung, or android?
Anything else I should know about you OR do you have any questions for me?
Do I have your permission to use pictures or feedback on social media?
Please select
Please list your Venmo/Cashapp/PayPal (for monthly payments)*
Signature (all purchases are final sale and non refundable)

First NameLast Name

My Products (If you do not have PayPal the form will not submit- please screenshot the form and send it to me and you can submit payment to Venmo buffduff__ or cashapp buffduff22)*

Customized Workout Program$125.00

Customized Workout Program catered to your goals

Macro Plan $225.00

Customized Macros, daily habits, weekly or biweekly checkins, app access

Macro Plan/Workout Program$280.00

App access, Work out plan, online support, Education, Baseline nutrition (customized macros), biweekly checkins, support group, grocery list, daily habits

Enter coupon

Total $0.00

Should be Empty:

Client Form