Welcome!
This is a self-assessment — not a sales page. The goal is to understand where you are, what’s working, what’s not, and whether working with TMD Wellness is the right fit.

Be honest. This is about readiness, not perfection.

First Name *

Last Name *

Email *

Date of birth

Your Current Reality:

1. What best describes your main focus right now? (Select up to 2) *

2. Where are you most stuck? (Select all that apply) *

3. How long has this been an issue? *

Less than 6 months

6-12 Months

1-3 Years

3+ Years

Support, Readiness & Fit

6. How committed are you to doing this the right way? *

Not Very

Somewhat

Very

Fully Committed

7. Are you open to coaching, guidance, and accountability? *

Yes

Yes, even when it's uncomfortable

Unsure

PEPTIDE & HEALTH READINESS

8. Have you ever used GLP-1s or injectable peptides? *

Never

Previously

Currently

Considering

If you are currently on a GLP-1 please input which one/ones:

9. Are you open to peptide support if aligned with your goals?

Yes

Maybe, need more education

10. Are you currently taking medications or supplements? *

Yes

Please list any medications or supplements:

Investment & Commitment

11. Working with TMD is an investment in your health. Which best describes you?

Ready to invest if accepted

Open, but need clarity on options

Not ready right now

Your honesty helps ensure this is the right fit.

Is there anything else you want me to know about you, your body, or your journey that feels important to share?

This isn’t about perfection — it’s about readiness. If you’re done repeating the same cycle and ready for structure, support, and a teammate committed to helping you win, working with TMD may be your next step.

Once you have submitted this application, the TMD Team will take a look and contact you within the next 24-48 hours. Thank You for being honest and wanting to invest in you!

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

By checking this box, I consent to receive non-marketing text messages from TMD Wellness about [USE_CASE_FROM_CAMPAIGN_DESCRIPTION]. Message frequency varies, message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

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