Content:  anti-aging and coaching, aging, REGISTRATION, anti-aging clinic, live longer, anti-aging, grow younger, neuropsychology,anti-aging clinic

 
 
 
 
   

                     
 
   

 
 

Established 1994
   

 
   
 


NEURO CLINIC'S.LONGEVITY PROGRAM
 TREATMENT APPLICATION FORM
 
 
 
     
     
 

SELF-TRANSFORMATIONAL PROGRAM

  

 
 

Invitational Program
 in Longevity

 

- Register for your Invitation today!
 Application Form below page
 

Anti-
 
     
     

      
 
 
 

 
APPLICATION FORM
 
>>  Application Steps:
Step 1. Submission of your application to the our Selection Panel for approval.
 Step 2. If offered a place course payment is required by bank wire or internet banking.
   

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    ** Firstly, how did you hear about the Clinic?   
      Referral  Google Search  Google Ad  Dr Zeus's Books
 
1.  Yes! Please accept my below application for a limited place in the next available 1-to-1
         Self Transformational Program..

              I am looking to use the customized Self-Transformational Program for:
                  - Health Reasons
                  - Life Extension / Age Reversal
                  - Overall Wellness 
                  - Performance
                 Program Goals: 
 
 
 
 *** Consultation, treatment regimen design and practice session with Dr Zeus:
     - Option 1. Videoconference  -or-  Option 2. In Person with Dr Zeus.
 
        Option 1.  1:1 Videoconference / Telephone with Dr Zeus:
 |     .   > Select below Program Rate and optional Post Mentor Support with Dr Zeus:

                   - Corporate Rate: $us2,895.00 -sponsored by Organization for Senior Manager / Leader /
                                       Director / Owner.
                - Optional Pre-Program introductory telephone interview / call with Dr Zeus.    -Yes Please!
                      - Standard, Personal Rate: $us2,495.00.
                 - I require a Special Financial Assistance Rate:
                             - If you have not already received an 'Offer of Financial Assistance' from us please
                               submit a 'Financial Need' Statement (on below Form).

                   Optional:  Plus Post Mentoring (not normally required)
                                       - 1-to-1 Telephone or Videoconference Support.
                                      -  # of Sessions: 1. 2. 3. 4. ($us285 per session)

 
 
 
         Option 2.  In Person with Dr Zeus. (Wait List -currently 4-5 week Wait) .
                             - Australian VIP Rainforest Retreat   
   
     Yes, I wish to have: a) my name put on the Wait List and, b) have Dr Zeus call me to discuss my needs and the 1-to-1, Two Day, private session with him.  
 
             
      Exclusive Limited Time Offer  
  I will be travelling with my partner and would also like them to have some sessional time with Dr Zeus (at no extra cost) as part of my Day's Program!		  

Details:

 
 
     Peaceful, Zen Retreat (set in a beautiful rainforest beside bubbling creek) on the Gold Coast,
            Australia  -$us4,450.  (Mutually suitable date)    		 
 
 

  

     - Location: World famous Springbrook Rainforest, Queensland, Australia
   - Recommendations can be provided for any required accommodation.
   - 20 mins away from Coolangatta airport, 50 mins from Brisbane airport, Queensland. 
   - Be picked up by Limo and driven to and from Retreat.
   - Wait List Update. Currently 4-5 weeks. Strictly limited number of booking dates available.
   - Required initial telephone interview with Dr Zeus.		  
  - Preferred Program dates  (Month and day/s) :  
.    
 
    Bangkok, Thailand  $us3,850   (Mutually suitable date. Any required accommodation not included)  
 
 
  - Preferred Program dates  (Month and day/s) :
 
 

2. Personal Details		  
   

 

Full Name:

 

Business Name:

 

Address & Zip:

 

State & Country:

 

Tel. #'s:

Home/Mobile:   Biz:

 

Email :

Biz: Personal:
   
Website :
Facebook Name:
   
 

Profession /  Position :

     
  On a scale of 1 to 10 how would you rate yourself on being extroverted, agreeable and open to try new things / experiences?  
   1.  2.  3.  4.  5.  6.    7.  8.  9.  10.
 
On a scale of 1 to 10 how would you rate yourself on being optimistic?
   1.  2.  3.  4.  5.  6.    7.  8.  9.  10.
 
Rate yourself on a scale of 1 to 10 whether you enjoy being challenged and changing yourself.
  1.  2.  3.  4.  5.  6.    7.  8.  9.  10.
 

 
 

Your Professional / Educational Background / 'People Development Experience':

 

 

 

 The Philosophy that guides your life:

 

 

Have you undertaken any previous life extension or wellness programs?

   

Medical, therapy or personal history we should be aware of:

 

   

Any Referral Names etc to support your application:


 
  
 

 

  

 
 
 
   
 
     

 

    


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