Application – Maxx Rejuvenation Shop

Regenesis Platinum™ Application

Private Year-Long Total Body Optimization

Please complete the application below. All submissions are reviewed to ensure alignment and suitability.

Full Name

Email Address

Phone

Age

City

State/Province

Country

Current Health & Performance

How would you describe your current health and performance?

What are your primary goals for the next 12 months? (Select all that apply)

Are you currently working with any of the following?

Experience With Optimization

Have you previously invested in high-level health, fitness, or medical optimization services?YesNo

If yes, approximately how much have you invested annually?

What did you feel was missing from your previous approach?

Commitment & Expectations

Regenesis Platinum™ is a year-long, actively managed optimization partnership. What appeals to you most about this level of structure and oversight?

How willing are you to follow structured protocols, check-ins, and ongoing adjustments?

What does success look like for you at the end of 12 months?

Investment Confirmation

Regenesis Platinum™ is a $17,000/year private engagement. This includes physician-guided optimization, required medications, personalized nutrition and training, and weekly optimization check-ins.

Are you comfortable with this level of investment if accepted?YesNoNeed More Information

Final Questions

Why do you believe Regenesis Platinum™ is the right fit for you at this time?

Is there anything else you would like us to know before reviewing your application?

Submission Note

Submission of this application does not guarantee acceptance. If selected, you will be contacted to schedule a private consultation.