Concierge Onboarding

Fill this form during the 5–10 min onboarding call with your new high-ticket client. All fields marked with * are required.

🎬Demo Mode — Quick Fill(for walkthroughs & training)

Click any preset to autofill this form. You can still edit any field before submitting.

Identity & Contact

Full Name *Email (LMS access) Phone / WhatsApp *E.164 format with country code

Location

City State For FB ad geo-targeting + regional food patterns

Demographics

Age *Date of Birth Optional — alternative to ageGender *Annual Income (Marketing only) Used for FB ad audience targeting; never in clinical logic

Clinical Baseline

Weight (kg) *Height (cm) *HbA1c % (most recent) *Diabetes Stage *Currently on any medication? Boolean only — we never capture type or dose (ADR-005)CGM device available? Determines Mode A (with-CGM) vs Mode B (no-CGM)Programme start date *

Phenotype Markers (Optional — improves personalization)

Waist circumference (cm) Waist–Hip Ratio Family history of Type 2 diabetes?

After submission, you'll see a confirmation script to read out to the patient.