What is your name? *

First, can you please tell us your email address so that our team can contact you? *

How did you find us? Please share their name so we can thank them *

Friend or Family Member's Name
Instagram (Which Account?)
Facebook (Which Account?)
LinkedIn (Who?)
X (Account Name?)
TikTok (Account Name?)
Print Publication (Which one?)
Radio (Which station?)
Other (Please specify):

Tell us a bit about your current health situation and how long you have been dealing with each issue. *

Thank you for sharing. We've helped a lot of people in your shoes, we just need to know if this is something you're committed to fixing.This question is required.

I'm so desperate to fix my health

I'm going to have to wait to see what my doctor suggests first

What have you done to try to improve your health? *

Why are you looking for one of our Functional Nutrition Consultants to help you with this? *

Why is it important for you to solve your health issues? *

How much time will you have available to dedicate to improving your health? *

I'm a stay at home parent or unemployed

I'm in between jobs now, but will soon be working full time

I only have part-time employment

I'm working full time

I have a full time job AND often work overtime

Do you have a spouse or children who you would also like to join you in our Natural Health Improvement program? *

Yes! Include my spouse

I have 1 child who will join me

I have 2 children who will join me

I have 3 children who will join me

I have 4 or more children who will join me

Check all that apply

How prepared are you for a Consultation with our experts? *

I haven't watched anything of Gerald's. Im just booking a call because I'm curious.

I've watched Gerald's Youtube videos.

I've read "The Pharmaceutical Myth" book.

I watched PLENTY of Gerald's videos! I'm in the NHIC Facebook Group, read his book, I've watched all of the client testimonials videos on his website.

I have attended Gerald's Standard Process and Mediherb or Cellcore practitioner (clinician level) presentations.

Check all that apply

Why do you think you'll be successful with our Natural Health Improvement Program? *

Do you believe you have what it takes to be accepted as a client? *

No. I'm not sure I'm prepared for the level of accountability I know your Functional Nutrition Consultants will demand of me.

I think so... I'm done playing victim. I'm ready to take charge of my health, even though I'm scared.

YES! I'll be a perfect client for this. I'll show up consistently and follow the Natural Health Improvement Program. I choose results, not excuses, and my comfort zone is not my priority.

How much are you prepared to invest in yourself to solve this problem once and for all? *

What is your phone number? *

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