Address *

Street Address

City

State

Country

Postal code

Please provide the following information:

Ethnicity *

How did you hear about us? *

AI Chatbot (ChatGPT, Claude, Gemini, Grok, etc.)

Friend/Family Referral (If so, who may we thank? Include details below)

Social Media (Facebook, Instagram, etc.)

Online Search (Google, Yelp, etc.)

Saw your window sign

Saw your A-frame sign

Flyer, newspaper, local gym or business advertisement, etc.

Event (Please specify below)

Other (Please specify below)

More details:

What is your primary goal? *

Losing fat

Gaining Muscle

Improving health

Optimizing performance

Please select what you are currently using, or have used in the past 6 months. Please check all that apply. *

GLP-1 / weight-loss medication: Ozempic, Wegovy, Mounjaro, Zepbound, Saxenda, Victoza, semaglutide, tirzepatide, retatrutide, other

Growth hormone / recovery peptide: ipamorelin, CJC-1295, sermorelin, tesamorelin, MK-677, HGH, other

Injury / wellness peptide: BPC-157, TB-500, thymosin alpha-1, MOTS-c, AOD-9604, GHK-Cu, PT-141, melanotan, other

TRT / HRT / hormone-related therapy: testosterone, estrogen, progesterone, thyroid medication, enclomiphene, clomiphene, hCG, anastrozole, other

None of the above

Menopause Status (This helps us better explain your DEXA results and identify general considerations for maintaining or improving bone density.) *

Not applicable / male customer

Premenopausal (Regular menstrual cycles)

Perimenopausal (Cycles are changing or becoming irregular)

Postmenopausal (No menstrual period for 12+ months)

Surgical/medically induced menopause

Prefer not to answer

Coaching Question:

Wellth Performance accepts 10 new clients into our private 1-on-1 coaching program each month. To ensure every client receives the highest level of support and attention, enrollment is by application and mutual fit only.

Would you like to apply for an upcoming opening? *

Yes, I’d like to apply

I’d like to learn more before I apply

No, I don't want guaranteed results

Wellth Client Agreement & Media Release

I have read and agree to the Wellth Client Agreement *

Check

I have read, understood, and agree to the Wellth Media Release.

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Please sign your name then press 'Submit' to complete your form.

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