Are you male or female?
Male
Female
What is your age?
What is your height? (feet and inches)
What is your current weight?
Are you currently taking any prescription medication?
Yes
No
I want to...... (select all that apply)
Focus on weight loss or management
Manage my hormone levels
Cope with menopause
Learn how to eat healthier
Cope with aging
Address my aesthetic concerns
Address sexual issues or dysfunction
Improve my overall quality of life
What are your weight loss goals?
Quick weight loss (<20 pounds)
Major weight loss (>20 pounds)
Maintain current weight
How motivated are you to lose weight?
Very motivated
Pretty motivated
Indifferent
Not motivated
What is your goal weight? (in lbs)
When was the last time you had lab work done to test your hormone levels?
Less than 6 months
6 months to 1 year
Over 1 year
Never
What are your primary areas of interest?
Wrinkle and/or anti-aging treatments (Face)
Overall skin health & rejuvenation (Face)
Hair growth (Head)
Sexual aesthetics (Intimate)
Other (Whole Person)
What are your primary areas of interest?
Erectile Dysfunction
Performance Enhancement
Peyronie’s Disease
Urinary Incontinence
Vaginal Rejuvenation
Other/I Don't Know
How would you rate your lifestyle?
Active (Exercise 3 to 5 times a week)
Semi-Active (Exercise 1 to 2 times a week)
A Little Active (Exercise 1 to 2 times a month)
Sedentary (Random exercise)
Very Sedentary (No exercise)
How would you rate your diet?
Very Healthy
Pretty Healthy
Kind of Healthy
Not Healthy
I'm not sure
What have been some of the biggest hurdles you've faced in achieving your goals?
What motivates you best? ....... (select all that apply)
Regular feedback
One-on-one guidance
Independent implementation
Rigorous challenges
Step-by-step implementation of ideas and challenges
Other
First Name
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Last Name
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Email
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Phone
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Which location do you prefer?
*
Clarkston MI
Rochester Hills MI
West Bloomfield MI
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Would you like to opt in to our newsletter?
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No
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Preferred Callback Time:
May we reach out to you via text?
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Yes
No
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