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First Name (required)

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Phone (required)

Where do you live? (required)

if you live outside the US, please share your Skype account name if you have one

How were you referred to us/ how did you learn of our practice? (required)
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Please list your top 3 health goals Separate by comma (required)

When was the last time you felt really well? (required)

What was going on in your life right before/around that time? (required)

What do you think needs to change in order for you to feel better?

You’ve just been handed a golden lamp with a genie inside….you get one wish. What do you wish for?

Are you willing to make dietary modifications, lifestyle changes, perform lab testing, take customized supplements, and be coachable?

Are you willing to invest $500 to $2,000 to begin the journey of reclaiming your health?(required)