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Health Mentoring Application
Fill Out This Form & Book a One-On-One With Dr. Nick
Fields marked with an
*
are required
First Name
*
Last Name
*
Phone
*
Email
Gender
Age
18-34
35-59
60+
Height
<5ft
5ft-5.5ft
5.5ft-6ft
Over 6ft
Weight
135 or less
136-155
156-185
186-205
206+
How important is your health to you?
*
Very Important
Somewhat Important
Unimportant
How important is the health of your family and friends to you?
Very Important
Somewhat Important
Unimportant
Describe what you are hoping to achieve with Dr. Nick:
*
How much are you considering to invest in your health?
*
<$500
$500-$2000
$2000-$10000
$10000+
How important does something have to be for you to make an investment?
*
If there is any chance it will help.
If it will likely help.
Only if it is absolutely going to get me my result.
How would you prefer to meet with your Health Coach?
I would prefer to only meet online.
I would like to have physical meetings only.
I would like a mix of both online and physical meetings.
Check all aspects of your life you would be willing to take to the next level to reach your goals:
My Diet & Supplements
My Exercise Routine
My Vices
My Attitude
When would you prefer to be contacted? (please include your time zone)
If you are real just type YES in the next box.
*
3 of 3 Character(s) left
If you are a human seeing this field, please leave it empty.
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