Please confirm your full name
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Please confirm your best phone number
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What do you want help with improving?
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How soon are you looking to make a decision on improving your memory?
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Immediately - top priority
Right now - this week or next
1-2 Months - this isn't urgent
Not anytime soon - just exploring
What's happening at the moment in your life that has you considering our brain fitness support and help?
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What's the best email for you, if we do think it is a good fit?
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