First Name *

Last Name *

Phone *

What's Your Best Email? *

Have you consumed any content from Dr. DeMartino on how we get results & how we are different? *

Yes, I have consumed alot of videos/blogs

Yes, but only a few

No, not at all

What diagnosis and symptoms are you dealing with? How long? *

When it comes to decisions about your health & finances, who else needs to be part of this conversation? *

I make these decisions independently

My spouse/partner/someone else would need to be involved

Will the other person involved in making the financial decision be joining the consultation? *

Yes

No

Which do you feel best describes where you are right now with your autoimmune/chronic illness? *

It's significantly affecting my daily life and I'm ready to do something different

I'm managing okay, but want to get ahead of where this is going

I'm still exploring my options and not ready to make any decisions

Are you aware that conventional medicine and insurance chooses not to cover care that directly addresses the root causes because they want you dependent on drugs, injections or surgeries? *

Yes

No

Dr. Rob's program minimum is $9,800 - do you believe that’s realistically possible for you? *

Yes

No

If you’re not financially ready today, what best describes your timeline? *

30 days or less

30-60 days

60-90 days

90+ days