Full Name *

Phone *

Email *

What Are You Most Interested In? *

Placing a small order with Super Patch and saving 25% off retail
Placing a bulk order of 40+ patches and saving 40% off
Opening a Practitioner Account to access wholesale pricing
Global Expansion — becoming a distributor in an open international markets
Building a business through Super Patch’s Corporate Team
Selling our Health & Wellness Program to corporations with 1,000+ employees
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Have you ever built a team? *

Yes

No

Are You Making More Than 2K a Month from Network Marketing? *

Yes

No

How soon are you ready to get started? *

Right Away!

In a Couple Months

In a Couple Weeks

Are You Willing to Invest $1,500 to Start a New Business? *

Yes

No, Thats too expensive

I'm not sure, lets talk

Why are you interested in this opportunity? *

I want freedom in my life

I want to make a difference in people's lives

I want to network with industry leaders

I want to join a community that provides support and leadership

Are you currently with a network marketing company? *

Yes, I'm looking for something new

Not Interested

Ive never done network marketing but im ready to learn more!

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