Treatment Application

What are you applying for ?

I'm a New Customer applying for the 12-Week Program I'm an Existing Customer applying for the Monthly Membership

What's your sex ?

Male Female Other

What's your age ?

< 40 40 - 49 50 - 59 > 60

What race/ethnicity do you belong to ?

What's your weight ?

What's your height ?

Are you diagnosed with one or more of the following cardiometabolic conditions listed below ?

Yes No

If yes, please specify !

Do you take prescription medication ?

Yes No

Do you have family members (grand-parents, parents, kids, brothers, sisters, uncles, aunts, cousins, nieces, nephews) who have gone or go through one or more of the following diseases, events, and/or symptoms listed below ?

Yes No

If yes, please specify !

Did you experience or do you experience one or more of the following diseases, events, and/or symptoms listed below ?

Yes No

If yes, please specify !

Have you had any medical examinations recently ?

Yes No

Are you under medical supervision, undergoing regular treatment, or about to undergo treatment ?

Yes No

How active are you ?

Did you or do you use tobacco products ? (including cigarettes, chewing tobacco, vaping, etc.)

Yes No

Do you consume alcohol and/or processed foods ?

Yes No

✎ PERSONAL INFORMATION

✎ DOCTOR INFORMATION

Do you have a referral from a doctor ? (If yes, we should receive or have already received the referral from the doctor)*

Yes No

I declare that the information given in this application is complete and accurate.

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