Type II Diabetes Application Form

Please complete the form below. Thanks

Describe Your Current Health Situation and Challenges: *

Did you watch the webinar to the end? *

Yes

No

What Goals Are You Hoping to Achieve with Our Help? *

What is Your Timeline for Seeing Improvements such as better glucose, lower A1c or weight loss? *

How Quickly Are You Looking to Make Changes to See Results in Your Health? *

Have You Worked with Any Diabetes Programs Before? If So, What Was Your Experience? *

Why Did You Choose to Reach Out to Us Specifically for Your Diabetes? *

On a Scale of 1 to 10, How Committed Are You to Improving Your Reversing Diabetes, Potential Complications and Overall Health? *

If We Decide to Move Forward, What Would Be the Next Steps on Your End? *

Most Diabetics Waste Money on the Sickness Versus Investing in their Own Health. Are You Able to Invest in Yourself Beyond Medicare to Improve Your Health? *

Yes

No

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

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