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First Name *

Last Name *

Phone *

Email *

Date of birth

Referred By

What would you MOST like to improve?(Select all that apply)

Increase strength

Improve posture

Build bone density

Move with less pain

Prevent falls / improve balance

Core Strength

Weight loss

Confidence in daily activities

Medical Safety Have you Ever Had Any Of The Condition Below? (Select all that apply) *

Deep Vein Thrombosis

Organ Transplant

Blood Thinners

Pacemaker

Detached Retina

None of the above

(These guide us on the safest tech & protocols for you.)

Current Conditions (check any that apply)

Osteoporosis/Osteopenia

Joint or back pain

Fracture (Specify below)

Pre-Diabetes / Diabetes

Loss of height / Posture changes

Other major medical issues (Specify below)

No Major Issues

Specify what you checked above.

Describe in detail

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I understand that this program is not a substitute for medical advice and I should consult my doctor before beginning any new physical activity.

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