Brain health and memory training registration form

1

What brings you to the program?Check all that apply

Prevention of Alzheimer's or memory loss

Memory training / building up cognitive reserve

Assessing / monitoring of memory function

Other

2

Do you have any current memory symptoms?

YESNO

3

If yes, please describe the symptoms

4

What is your name?The name of the person who is being registered

First Name

Last Name

5

Email* This field is required.

example@example.com

6

Phone Number* This field is required.

Please enter a valid phone number.

7

Where are you based?

United States

Rest of World

8

Which US State are you based in?

9

Which country are you based in?

10

Your birthdate

Date

11

How did you hear about us?

12

Which membership option are you interested in (you can always upgrade)

Free trial (free initial consultation and memory self-assessments)

Full membership, paid ($50 per month, full access to medical consultations and neuropsychological evaluations)

Full membership with insurance or Medicare coverage, paid ($10 per month, as per full membership)

13

Now book your free initial consultation appointmentYou can also skip this step for now and click submit if you prefer