BODY MAX HARMONICS Practitioner Membership Application

BODY MAX HARMONICS Practitioner Membership Application
IMPORTANT— PLEASE READ BEFORE COMPLETING THIS FORM:

Body MAX Harmonics is a wellness education platform operated by an unlicensed alternative health and wellness practitioner. Membership is open to health and wellness practitioners regardless of licensure status —licensed, certified, and non-licensed practitioners are all welcome. All members, regardless of credential status, are solely responsible for all decisions made in connection with their use of program materials, and must accurately represent their own qualifications to their clients at all times. A full Practitioner Acknowledgment & Responsibility Agreement will be provided for signature before membership is activated.
Name*

First NameLast Name
Preferred Name (if different)
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Professional Credentials & Background
Credential Category *
Other Credential(s) or Designation
If answered other above
Relevant Training, Certifications, or Education Background (all practitioners— list any certifications, courses, diplomas, or programs completed relevant to health and wellness)
The following fields apply to Licensed and Certified Practitioners only. Non-licensed practitioners may skip to Professional Certifications below.
Primary License Number (if applicable)
Issuing State / Province / Country (if applicable)
Additional License Numbers (if applicable)
Issuing Jurisdiction(s)
NPI Number (if applicable)
License Expiration Date (if applicable)

MonthDayYear
Date
License Status (Active / Inactive / Pending — if applicable)
Professional Certifications / Specialty Designations (e.g., IFMCP, NBHWC, ABAAHP —list all)
Licensed / certified practitioners: Is your credential currently in good standing with no pending investigations, suspensions, or disciplinary actions? (N/A if non-licensed)

YesNoN/A
Do you carry active professional liability or wellness practitioner insurance?

YesNo
If yes — Insurance Provider and Policy Number (for our records only)
Practice Information
Practice / Business Name*
Practice Setting (select all that apply)*

Solo private practiceGroup practice / clinicIntegrative / Functional medicine clinicTelehealth onlyHospital / health systemCoaching practice (online)Naturopathic / Holistic clinicChiropractic clinicPharmacy-based wellnessEmployer wellnessAcademic / researchOther
Practice Website (if applicable)
Years in Practice*
Approximate Number of Active Clients / Patients
Primary Clinical or Wellness Focus Areas*

Longevity / healthspanMetabolic healthNeurological wellnessHormonal healthGut health / microbiomeAutoimmune / immune supportCardiovascular wellnessCognitive healthWeight & body compositionFunctional nutritionSports / performancePost-viral recoveryDetoxificationGeneral wellnessPediatric wellnessWomen's healthMen's healthOther
Describe your current client population — who do you primarily serve?*
What tools, testing, or platforms do you currently use in your practice?(e.g., Fullscript, specific lab panels, EHR, health coaching platforms)
Education & Continuing Education Background
Highest Degree Earned*
Institution
Have you completed any training in the following areas? (select all that apply)

Functional medicine (IFM or equivalent)Integrative medicineNutritional biochemistryGut microbiome / GI healthPrecision medicine / genomicsLongevity / anti-aging medicineNeurological wellnessPeptide therapyHormonal optimizationLifestyle medicine (ACLM)Health coaching certificationMind-body medicineOther
List any other relevant advanced training, fellowships, or certifications not captured above:
Program Fit Questionnaire

The following questions help us understand how Body MAX Harmonics can best support your practice and ensure the program is the right fit for you. Please answer thoughtfully —there are no right or wrong answers.
How did you hear about Body MAX Harmonics?

Colleague referralSocial mediaSearch enginePodcast / interviewProfessional conferenceEmail / newsletterExisting member referralOther
If referred by a colleague or member — please provide their name:
In your own words, describe your current approach to client care. What makes your practice different from a conventional model? *
What are your biggest clinical or practice challenges right now? *
What specific outcomes are you hoping to achieve for your clients through this membership? *
Which of the following best describes your familiarity with the gut-brain axis and precision neurological wellness?

New to this area — looking to learnSome background — want to deepen my knowledgeWorking in this area actively — want structured protocols and supportAdvanced practitioner — looking for peer community and latest research
Which of the following topics are you most interested in developing further through this membership?

Gut microbiome and neurological healthTMAO / dietary-microbial neurotoxicityMitophagy and cellular energy supportKynurenine pathway and tryptophan biologyPlasmalogen and membrane restorationHOCl / ReBalance gut rebalancing protocolsPrecision biomarker monitoringGLP-1 pathway and metabolic-neurological connectionUrolithin A and longevity supplementationInfectious neuroinflammationDopaminergic nervous system wellnessProtocol design for complex clientsClinical research participationPractice building and business developmentSupplement dispensing and FullscriptAddiction ProtocolsDental ApplicationsOther
How many hours per week are you typically able to dedicate to professional development and continuing education?

Less than 1 hour1-2 hours2-4 hours4+ hoursOther
Are you currently using any protocols or frameworks from other precision health, functional medicine, or longevity education platforms?

YesNo
If yes — which platforms or programs?
Do you currently use FullScript to dispense supplements to clients?

YesNo
If no — are you interested in setting up a FullScript account as part of your membership?

YesNo
Have you worked with clients who have neurological conditions, neuromotor presentations, or neuroinflammatory concerns?

YesNo
If yes — briefly describe the types of presentations you have worked with:
Are there any specific client cases, conditions, or clinical questions that prompted your interest in this membership? (optional —general terms only, no identifying client information)
What is your primary goal for your practice over the next 12 months? *
Is there anything else you would like us to know about you, your practice, or your goals before your alignment call? *
Membership Tier Interest

Review the three membership options below and indicate your initial interest. Your final tier selection will be confirmed during the alignment call based on your scope of practice and goals. There is no obligation at this stage.
All memberships require a 3 month commitment MINIMUM

ESSENTIAL - $300 / month

+ Full protocol library

+ Community forum

+ Recorded weekly calls

+ Certification (audit)

FOUNDATION - $500 / month

+ Everything in Essential

+ Live weekly calls

+ 3 support requests/month

+ Certification enrolled at discount

APEX - $800 / month

+ Everything in Foundation

+ 3support requests/month

+ Mentorship track

+ Early protocol access

+Certification Program
I am Interested in...
Final tier selection is made during your alignment call. Annual billing options with (10-15% savings) are available and will be discussed during onboarding.
Acknowledgments & Declarations

Please read each statement carefully and check to confirm your understanding.
Acknowledgments & Declarations*

I understand that Body MAX Harmonics is operated by an unlicensed alternative health and wellness practitioner. All program materials are wellness education resources only — not medical advice, diagnosis, treatment, or clinical prescriptions from a licensed healthcare provider.I understand that regardless of my own credential or licensure status, I am solely and fully responsible for all decisions I make in connection with my use of any Body MAX Harmonics material with my clients.If I am a licensed or certified practitioner: I will apply Body MAX Harmonics materials only within my licensed or certified scope of practice. If I am a non-licensed health practitioner: I understand I am not authorized to diagnose, treat, prescribe, or practice medicine, and I will not represent myself as doing so.I understand that I must be transparent with my clients about my own qualifications and the non-medical nature of the wellness support I provide, and that I must refer clients with suspected or diagnosed medical conditions to a licensed physician for medical assessment and management.I understand that I must never advise clients to stop, modify, or delay any prescribed medication based on Body MAX Harmonics program contentI agree not to reproduce,resell, sublicense, distribute, or share Body MAX Harmonics protocols or materials outside of my direct client-practitioner relationships.I confirm that all information provided in this application is accurate and complete to the best of my knowledge.I understand that a full Practitioner Acknowledgment & Responsibility Agreement will be provided for signature before my membership is activated and that my membership is conditional on executing that Agreement.I understand that Body MAX Harmonics reserves the right to decline any application without explanation.
Signature & Date

By signing below, I confirm that I have read, understood, and agree to all statements in Section 7, and that all information provided in this application is accurate and complete.
Full Legal Name*

PrefixFirst NameMiddle NameLast NameSuffix
Signature*
Date*

MonthDayYear
Date
Should be Empty:

BODY MAX HARMONICS Practitioner Membership Application

IMPORTANT— PLEASE READ BEFORE COMPLETING THIS FORM:

Professional Credentials & Background

The following fields apply to Licensed and Certified Practitioners only. Non-licensed practitioners may skip to Professional Certifications below.

Practice Information

Education & Continuing Education Background

Program Fit Questionnaire

Membership Tier Interest

Acknowledgments & Declarations

Signature & Date