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Please fill out and submit this form so we can discover if it makes sense to work together.
15
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1
Which of these apply to you?
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This field is required.
What are the things bothering you that you want to change?
I have less muscle and more fat than I want
My mental clarity or memory is not optimal
I have low energy and/or low motivation
My libido or sexual performance is not what it once was
I feel past my prime
I want to age more youthfully
Under age 38
Other
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2
Describe other
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3
What are your top health or performance goals over the next 6-12 months
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Be Very Specific.
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4
What has been the biggest obstacle to achieving your goals?
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Ok
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5
Best Email
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so we can contact you
example@example.com
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6
Name
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First Name
Last Name
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7
Cellphone Number
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Area Code
Phone Number
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8
What do you do for a living?
*
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Entrepreneur, Founder, Business Owner
Executive (CEO, COO, CMO, VP, etc)
Professional (Physician, Dentist, Lawyer, Chiropractor, Finance, etc)
Employee
Retired
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9
What did you do before retiring?
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10
What significant commitments have you made in yourself in the past?
*
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Check all that apply
One-to-one personal trainer, heath coach or concierge physician
High ROI Mastermind or business coach
Hormones, peptides, Hgh, full body scan
Peloton, Tonal, Infrared Sauna, Whoop, Oura Ring
Gym membership, workout plans nutritional supplements
Never invested in any program or service in these categories
Other
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11
Describe other
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12
Are you willing to hire a concierge physician to help you accelerate your performance?
*
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Become the best version of yourself
Definitely!
No
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13
High-end customizable services focused on age management, optimizing performance and healthy longevity are rare. They are designed for high net worth individuals with busy lives who are prepared to invest their time, focus and a minimum of $12,000 towards making health a priority. Are you ready to invest in your health?
*
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Yes, I have time and resources now
No, I don't have resources to invest now
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14
How soon are you willing to begin investing in your health?
*
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Today!
1 week
Next month
Now isn't the right time, just looking for information
I'm undecided if this is right for me
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15
Do you confirm that you will show up to your scheduled call on time and distraction free?
*
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YES, I WILL
NO
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