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Intake form
Help us serve you better
Name
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Email address
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What is your age group?
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18-24
25-34
35-44
45-54
55-64
65 and above
What is your gender?
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Male
Female
Non-binary
Prefer not to say
What is your current employment status?
Please select at least one option.
Employed
Self-employed
Unemployed
Student
Retired
Which health conditions do you currently have?
Please select at least one option.
Diabetes
Hypertension
Asthma
Heart Disease
None
What are your primary wellness goals?
Please select at least one option.
Weight Loss
Improving Fitness
Stress Management
Nutrition
Mental Health
Preventive Care
What type of insurance benefits do you currently have?
Please select at least one option.
Health Insurance
Dental Insurance
Vision Insurance
Life Insurance
Disability Insurance
How did you hear about us?
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Social Media
Search Engine
Friend/Family
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Additional questions or comments
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