REBUILD Application

First name

Last name

Email

Phone

Which of the following are you experiencing?

On a scale of 1–10, what is your average pain level on most days?*

Where exactly is the pain located?

How long have you been dealing with this?

Have you tried physiotherapy or any other treatment? If yes, what was the outcome?

Are you currently under any medical advice or restriction on physical activity?

Yes

No

Other

Any medical reports you may have that help us understand the situation better.

How did you hear about this program?

If selected, the program involves an minimum investment of ₹ 50,000/- + 5% GST. Are you ready to make this investment?

Yes, I am ready to make this investment.

No, I am still not sure about the investment

Other

I accept that to apply for the program, I will have to pay ₹ 499/- which will be refunded in full if I am not selected. If selected, I confirm to attend the assessment call at the mutually decided time failing which the application fee may be forfeited.

After successful payment, our team will review the application and reach out to you within 48 hours to update you on the status of your application.