Let’s start with where you are now

Date of birth *

Your height *

Your current weight *

Gender at Birth *

Female

Male

Are you currently taking any medications? *

Yes

No

Which of the following symptoms have you experienced in the past 6 months? *

Fatigue

Weight gain

Hair loss

Mood swings

Decreased libido

Sleep disturbances

Memory problems

Hot flashes

Muscle weakness

How severe are your symptoms on a scale of 1 to 10? *

1 (Mild)

2

3

4

5 (Moderate)

6

7

8

9

10 (Severe)

What are your primary health goals? *

Weight management

Maximize sexual performance

Balance hormones

Improve skin elasticity

Build muscle mass

Increase energy levels

Have you tried any hormone-related treatments before? *

Yes

No

Considering our program is out-of-pocket, as insurance DOES NOT cover it, how committed are you to invest in your weight loss goals? *

I'm fully committed and willing to invest.

might need some financial options or a payment plan.

I'm not ready to invest at this time.

First Name *

Last Name *

Email *

Phone *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

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