Founders Club Application Founders Club Application This form will serve as the initial screening survey for admission into ReYOUvenate's Founders Club. Full Name* First Last Date of Birth* MM slash DD slash YYYY Email* PhoneList any Medical Diagnoses*Prescribed Medications List (currently taking)*What (If Any) Supplements Are You Currently Taking?What Are You Looking to Address?* Pain Chronic Illness Autoimmune Disease Gut Health Anti-Aging Health Optimization Other If You Selected Other, What are You Looking to Address? How Did You Hear About The Founders Club? Dr. Fortin/The Reyouvenate Clinic Social Media (Facebook, Instagram, YouTube) A Friend/Referral Reyouvenate's Emails Other If You Selected Other, How Did You Hear About The Founders Club? If You Selected Friend/Referral, Who Referred You? The Cost to Participate in The Founders Club Annual Program is $8,000 for an Individual or $12,000 for a Couple. At what level are you planning to participate?* Individual — $8,000 Couple — $12,000 Partner's Name* First Last Partner's Email* Please check if you are not able to fill out the application on your partner's behalf at this time, and we will email them the application separately. Email a Separate Application to my Partner Partner's Date of Birth MM slash DD slash YYYY Partner's Medical DiagnosesPartner's Prescribed Medications List (currently taking)What (If Any) Supplements Is Your Partner Currently Taking?What Is Your Partner Looking to Address? Pain Chronic Illness Autoimmune Disease Gut Health Anti-Aging Health Optimization Other If Selected Other, What Is Your Partner Looking to Address?