PRE-DISCOVERY FORM

First Name *

Last Name *

Email *

Phone *

Did someone refer you to Dr. David Yerkes?

What is your biggest health concern right now? *

In an ideal world, how would the healthiest version of you look and feel? *

Right now, what is your Number 1 obstacle to achieving your goal? *

Briefly tell me about your current status and what you are currently doing or have done in the past to try to solve the problem you described above.

How long have you been struggling with this problem?

Right now, I... *

Have the financial resources to invest in a curated high-performance health optimization program

Have access to the resources and am prepared to invest if it’s the right fit

Do not currently have financial resources, but I may be open to sponsorship, partnership, or ambassador-style opportunities if there’s alignment

Do not currently have financial resources, and I am NOT open to sponsorship, partnership, or ambassador-style opportunities

Do you promise to show up for your scheduled appointment ON TIME and DISTRACTION FREE? Please confirm by typing "Yes I will" in the box below. *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.