First Name
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Last Name
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Email
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Phone
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Age
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Male or Female?
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Height (feet & inches)
Current Weight (lbs.)
Weight Goal (lbs.)
What's your #1 challenge you're facing with your health or performance right now?
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What's your main motivation for wanting to join one of our transformation programs?
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Briefly describe your current situation including your health, fitness, performance and any issues
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What medications/supplements are you currently using? Dosage & Schedule. Provide as much detail as possible.
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What is your recent medical history, if related to your situation? (Prior test results, treatments, surgeries, imaging, etc.)
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Problems and concerns? Current condition and symptoms
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What transformation program are you interested in?
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I'm interested in Total Scientific Augmentation
I'm interested in Health & Performance Transformation
I'm interested in the Private Access Consultation
I'm interested in the Personalized Action Plan
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What are your top 3 goals you'd like to achieve with the coaching program?
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Do you believe that Brenden Henry, Dr. Ali and the transformation specialists at the Institute of Scientific Augmentation can get you there?
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Yes
No
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Upload any relevant documents or pictures. Ex: Blood Work, Labs, Conditions
Additional details or commentary
By submitting this application you understand that this is a substantial investment in your future, and you are prepared to commit the time and resources to get the results that are possible. How would you best describe your commitment level right now?
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I am committed to my future and ready to go
I am not committed to my future and I'm not ready to go
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We will let you know if we require any further information. Thank you!