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Sometimes
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Email Address
What’s your best email?
Name
What’s your full name?
Phone
What’s your best phone or WhatsApp?
Country
Where are you currently based?
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua & Barbuda
Argentina
Armenia
Aruba
Ascension Island
Australia
Austria
Azerbaijan
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Belarus
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Bolivia
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Burundi
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Canada
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Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
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Gambia
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Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
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Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Island
Honduras
Hong Kong SAR China
Hungary
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India
Indonesia
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Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
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Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao SAR China
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
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Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
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Nigeria
Niue
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Panama
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Paraguay
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Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and South Sandwich
South Korea
South Sudan
Spain
Sri Lanka
St. Barthélemy
St. Martin
St. Pierre & Miquelon
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria
São Tomé & Príncipe
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Turks & Caicos Islands
Tuvalu
U.S. Virgin Islands
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America (USA)
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Wallis And Futuna Islands
Western Sahara
Yemen
Zambia
Zimbabwe
Membership Interest
Essential Concierge Care
Executive Concierge Care
Pinnacle Concierge Care
I’m not sure at the moment
Main Health Concerns
Health & Longevity Optimization
Health Improvement – Chronic Issues
Nervous System Overload – Anxiety, Brainfog
Hormones / Libido / Energy
Gut Issues / Metabolism / Weight
Other
What clinics have you tried and what could they have done better?
MindO2 Method –
Do you feel anxiety, stress, emotional pressure, or nervous system overwhelm may be affecting your physical health?
Yes, Definitely
Possibly
Not Sure
My Sleep Affected
No, All Is Well
Survival Mode Question
Do you often feel like your body is stuck in survival mode, even when you try to rest?
Yes
Sometimes
Not Sure
No
Desired Outcome
Upload Latest Lab Results
Not a prerequisite, but most helpful in health strategy planning. Accepted files: PDF, JPG, PNG
Drag and Drop (or)
Choose Files
Ready To Begin
If Accepted As a New Member, Are You Ready To Begin Within 14-Days?
Yes
Possibly
Not Yet
I understand this application does not create a doctor-patient relationship and is used to determine suitability for concierge care.
*
Yes, I agree with the
privacy policy
and
terms and conditions
.
Submit Application
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Expand
Advanced Diagnostics
MindO2
Rx On-demand
IV Therapy
Peptides
Hormones
Functional Nutrition
Conditions
Oral Health – Second Opinion
Contact Us
About Us
