Register - Dr. Cori Cooper

Instructions

Please complete the form below to begin the process for identifying the best supplement pack for you that also includes access to the Social Wellness Club. This form only collects your information, you will not be charged until you have been contacted by phone to confirm the best supplement pack for you that addresses your specific health goals. Your membership includes your supplements and a private members only community full of encouragement, hope, and practical tips to support you on your health journey. You will receive access to the member community after your order has been processed.

Name*

First Last

Date of Birth*

Phone Number*

Email*

Billing Details

Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name on Card*

Credit Card Type*

Credit Card Number*

Expiration Date*

CVV2 Security Code*

Shipping Address*

Same as billing address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Additional Information

Please let us know important health-related information by answering each question below.

What is your primary health concern?*

Please list any allergies or sensitivities you have so that we can customize your product package to meet your needs.*

Are you currently taking any nutritional supplements or medications? If so, please list all.*

Are you currently a VIP Customer or Brand Ambassador for Plexus Worldwide?*

Yes
No

Did someone refer you to this program? If yes, who? Please include their First and Last Name below.*

Is there anything else you'd like us to know?*

Disclaimer*

As with every health & wellness program, please check with your medical doctor before starting this program. The information in Do Diabetes Differently® is meant for educational purposes only. The information in this program is not intended to serve as medical advice and should not be used for the diagnosis or treatment of a health problem or disease. This program is not a substitute for professional medical care.

Yes, I have read the disclaimer and agree to the terms stated.

Name

This field is for validation purposes and should be left unchanged.

dr. cori cooper

dr. cori cooper

dr. cori cooper

Social Wellness Club Intake Form

Instructions

Billing Details

Additional Information

DR. CORI COOPER