Wufoo
Please Complete This Blood Sugar Application
Thanks for your interest in Dr. Mowll's Blood Sugar program. Once you complete this form and click to submit, you will be taken to a page to schedule your complimentary phone call.
What's your name?
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First
Last
What is your primary email?
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Have you been medically diagnosed with any of the following?
Type 2 Diabetes
Pre-Diabetes
Metabolic Syndrome
Other/None
If so, when were you diagnosed?
What are you hoping to achieve through Dr. Mowll's blood sugar program?
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What is your MOST RECENT hemoglobin A1c reading?
What treatments or medications are you currently using?
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How do you think your current treatment approach is working (or not working)?
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What is your occupation, and do you consider your work more active or sedentary?
What does a normal day look like for you? (work, hobbies, exercise, kids, grandkids etc.)
If Dr. Mowll can accept you as a client, how much are you willing to invest in health in order to improve your blood sugar and reverse diabetes?
0-$100 (I don't have any money to invest in my health)
$100-$1,000
$1,000-$5,000
$5,000+
How do you typically make decisions regarding your healthcare (that involve an investment in time and money)?
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I make all my own decisions
I typically make decisions with my spouse
My spouse makes all decisions involving money
Have you been able to watch the webinar on "The Four Step Approach To Master Blood Sugar And Reverse Type 2 Diabetes Without Depending On Medications?"
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Yes
No
Some of it
Not sure
What is the best number to call?
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If you'd like to include labs or other information, you can attach them here:
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