APPLICATION FOR

THE POWER TO HEAL PROGRAM™

Your Full Name? *

Preferred Email Address *

Your cell phone number to receive messages from us about your application *

This is to ensure you receive notification from us regarding your application as sometimes emails are lost in the cosmos. We will never sell or use this number for anything other than the use it is intended

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

What are you looking to achieve in your journey to health? *

Disease Remission

More Energy

Pain Reduction

Better Sleep

Joy for Life

Deeper Spiritual Connection

Increased Strength and Flexibility

Vibrant Mental Health

Discovering Life Purpose

You may choose more than one

How long have you been experiencing chronic physical health symptoms? *

Less than 2 years
2-5 years
5-10 years
10-15 years
15+ years
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What is your top challenges when it comes to living with chronic physical and/or mental health symptoms? *

Point form answers are acceptable

On a scale of 1-10, how committed are you to doing whatever it takes to solve this problem NOW? *

1 - Not Ready

10 - I am SO Ready! (Hint: This is where you need to be to join this program!)

I acknowledge this is a robust whole person program and I have gone through ALL of the content about the Power to Heal Program™. Including the 3 Day Minicourse and the Power to Heal Program overview video *

Yes

Special Payment Option Required? - Check yes if you are looking for the Extended Payment Plan or the Entrepreneur/Corporate Health Mentorship Option *

Yes

(For pay in full or the six month payment plan, please select "No")

Select Payment Option

Extended Payment Plan ($555 x12)

Entrepreneur/Corporate Health Mentorship

We have limited opportunity for extended payment plans, please specify circumstances in the "anything to add" section

Anything else you would like to add?