JR Longevity

JR Longevity Membership Application

Preview only: this application can be filled in and reviewed, but it is not yet submitted to the practice.

Welcome. Thank you for your interest in joining JR Longevity.

This short application helps us understand who you are and what brought you here. Most applicants complete it in 10 to 15 minutes. If accepted, your next step will be a 20 minute Discovery Call with our practice a conversation about how we work, what you're looking for, and whether we're the right fit for each other.

Membership is currently limited to Texas residents and capped at a small number of patients to preserve the depth of care we offer.

Section 1 About You

Full Legal Name:Preferred Name (if different):Date of Birth:Email Address:Phone Number:

Best way to reach you for next steps:

EmailPhoneText

Are you a Texas resident currently living in Texas?

YesNo (we are currently only able to serve Texas residents)

City and ZIP code where you live:

Begin with
a conversation.

JR Longevity Membership Application

How important is each of the following to you?

Review your membership application