Vitality X is a cutting-edge human optimization program designed to help individuals reclaim energy, reduce stress, and unlock peak performance across Body, Mind, and Heart. Built on the principles of biohacking, longevity science, and ancient intelligence, Vitality X delivers a structured, data-driven approach to vitality that fits seamlessly into modern lifestyles.

Complete Application Below

First Name *

Last Name *

Phone *

Address *

Street Address *

City *

State *

Country

Postal Code *

Email *

Emergency Contact Name *

Emergency Contact Number *

Suitability for ESWT (Extracorporeal Shockwave Therapy), also known as Softwave Tissue Regeneration Technologies.

Have you been injected with cortisone this month? *

Yes

No

Are you using a cardiac pacemaker? *

Yes

No

Do you have cancer / tumor? *

Yes

No

Do you have a skin infection? *

Yes

No

Are you pregnant or do you suspect you may be pregnant? *

Yes

No

Are you under 16 years of age? *

Yes

No

Sport or Activity *

What area of your health and performance do you most want to optimize right now? *

Body – I want to reduce pain, improve mobility, and optimize my physical health through therapies, bloodwork, and supplements.

Mind – I want to enhance focus, memory, and mental resilience through neurotraining and cognitive optimization.

Heart – I want to improve my metabolic health, breath efficiency, and emotional alignment using advanced diagnostics and breathwork.

All of the above. I am ready for a full Longevity X transformation.

RISK OF THIS PROCEDURE

A) Pain and soreness. This is temporary and resolves after a few days.

B) The FDA has labeled this a “Non-Significant Risk” therapy

Consent for Procedures, I, the Undersigned, do hereby consent to authorize the application of Extracorporeal Shockwave Therapy (ESWT) for my condition. I have been fully informed of ESWT which the use of has been fully explained to me by my treating physician/staff, and I fully understand the nature of this treatment. I also confirm that I have been given the opportunity to discuss and clarify any concerns and that no guarantees have been made to me mostly for pain relief and may offer an improvement of function. I also understand foregoing treatment is not the first option for my condition and an alternate treatment has either already been provided or offered to me. *

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Today's Date *

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By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.VerdanaParagraph10px1.5By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.VerdanaParagraph14pxy checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.