Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you consider yourself coachable? *

Yes

No

Do you have a supportive spouse, significant other, or friend to support your personal goals? *

Yes

No

Have you experienced significant trauma (emotional, physical)? *

Yes

No

Who else have you worked with? *

Functional Medicine Practitioner

Medical Doctor

Medical Specialist

Naturopathic Doctor

Osteopathic Doctor

Traditional Chinese Medicine

Nutritionist

Personal Trainer

Chiropractor

Personal Development Coach

Other:

What functional lab testing have you had done? *

Functional Stool Testing

Organic Acids Testings

Genetic or Genomic Testing

Hormone Testing

Heavy Metal Testing

None

Other:

Are you willing to do what's necessary to reclaim your health? (This may include, dietary modifications, functional lab testing, lifestyle and environmental modifications) *

Yes

No

If we can find a natural solution to permanently address your health issues, are you capable of investing a minimum of $2999? *

Yes

No