Founders Club Partner Application Founders Club Partner Application Your partner has filled out their application to The Founders Club. Please provide your information below to complete the partner application process. What is the Name of Your Partner Participating in the Program with You?* First Last What is Your Partner's Email? (This will be used to match your applications)* Your Full Name* First Last Your Date of Birth* MM slash DD slash YYYY Your 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?