Executive Full Health Management Form

First Name *

Last Name *

What are your top 3-5 health challenges right now? *

What interventions have you tried in the past that have NOT succeeded in resolving your issues? (For example: diet, cleanse, medication, supplements, reducing stress, bouncing around between doctors, etc.)

How long have you been dealing with this health issue? *

What are your biggest fears and frustrations when it comes to your health? *

I want to understand, which areas of your life are being impacted by your current state of health? *

Imagine for a moment that your current health challenges are a thing of the past and you are thriving, not only in your health but in every area of your life. What do you see is now possible? What would excite you most about life? What goals would you now be able to achieve? What are your greatest desires? *

Every person who works with Dr. Alicia is different and therefore every person needs customized solutions that are delivered in a way that works best for them. Dr. Alicia invests a lot of time and energy into ensuring the success of each of her clients.

Before you are invited to participate in Dr. Newsome's Executive Health Management Package, please note that Dr. Alicia and her team only work with a few select women who are ready to invest the necessary time, energy and money into identifying and resolving the root causes of their hormonal imbalances & health issues.

Please indicate what level of involvement you're ready to commit to: *

Yes. I am ready to go!

Yes, and I need a payment plan.

Yes, but I have a few questions.

I would love to join, but I cannot financially invest at this time

I’m not really sure, I am just here looking for information.

Tell me one of the things your are most excited to complete once you get your health back? *

Where did you first hear about Dr. Newsome? *

Please confirm you email address *

Optional: What is your Instagram handle & Linkedin? We’d love to connect with you on social media!

We kindly request that you provide a contact number for communication purposes related to your application. Your consent to be contacted by our team is necessary when sharing your phone number with us. Please note that your privacy will be respected. *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.