The Prevail Compass™

Name

Address

City, State, Zip, Country

Phone Number

How did you first hear about Prevail Over Cancer?

Name of referral source

Cancer type and stage

Month and year of diagnosis

Current treatment status

Describe your current treatment in more detail

Who is on your conventional care team?

Current prescription medications

Current supplements

Are you the cancer patient or a caregiver?

I am the cancer patient

I am a caregiver — my loved one has cancer and I am applying to build their protocol

Both — I have cancer and I also support a family member with cancer

Current diet

Diet consistency

Very consistent — I follow it closely most of the time

Mostly consistent — some days are harder than others

Working on it — I know what I should do but struggle to follow through

Just getting started — I haven’t made changes yet

Integrative strategies you’ve already tried

Your single biggest challenge right now

What have you tried that hasn’t worked — or that you’re uncertain about

The single most important thing you want to accomplish

What success looks like at 35 days

Please explain your commitment number

Anything that could make full participation difficult?

Why this program? Why now?

Which tier are you most interested in?

Standard Live — $1,997 (5-Day live + 30-Day Track + recordings + deliverables + community)

VIP Live — $2,997 (Standard + 5× 1-hour pre-session personal review with Keith) · 6 seats max

Standard + 12-Week Coaching — $3,497 (full 35-day program + 12-week implementation coaching)

VIP + 12-Week Coaching — $4,497 (full VIP + 12-week coaching · maximum support)

Not sure yet — I’d like to discuss options on the fit call

Payment preference

Pay in full at enrollment

Payment plan via Klarna — available at Kajabi checkout

Not sure yet — I’ll decide after the fit call

Anything else Keith should know before your fit call?

I understand submission does not guarantee enrollment and a fit call follows

I understand The Prevail Compass™ is an education and coaching program, not medical treatment, and does not replace my conventional care team

I will complete all pre-work before Day 1 (delivered July 1, due July 4) and consent to session recording

Full name as typed signature

Today's Date

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