<!-- Begin MailChimp Signup Form --><!-- [et_pb_line_break_holder] --><link href="//cdn-images.mailchimp.com/embedcode/classic-10_7.css" rel="stylesheet" type="text/css"><!-- [et_pb_line_break_holder] --><style type="text/css"><!-- [et_pb_line_break_holder] --> #mc_embed_signup{background:#fff; clear:left; font:14px Helvetica,Arial,sans-serif; }<!-- [et_pb_line_break_holder] --> /* Add your own MailChimp form style overrides in your site stylesheet or in this style block.<!-- [et_pb_line_break_holder] --> We recommend moving this block and the preceding CSS link to the HEAD of your HTML file. */<!-- [et_pb_line_break_holder] --></style><!-- [et_pb_line_break_holder] --><div id="mc_embed_signup"><!-- [et_pb_line_break_holder] --><form action="//sela.us15.list-manage.com/subscribe/post?u=f8f4f82230881e41a39bdd0f1&id=15c66572f1" method="post" id="mc-embedded-subscribe-form" name="mc-embedded-subscribe-form" class="validate" target="_blank" novalidate><!-- [et_pb_line_break_holder] --> <div id="mc_embed_signup_scroll"><!-- [et_pb_line_break_holder] --> <!--<h2>Subscribe to our mailing list</h2>--><!-- [et_pb_line_break_holder] --><div class="indicates-required"><span class="asterisk">*</span> indicates required</div><!-- [et_pb_line_break_holder] --><div class="mc-field-group"><!-- [et_pb_line_break_holder] --> <label for="mce-FNAME">Name </label><!-- [et_pb_line_break_holder] --> <input type="text" value="" name="FNAME" class="" id="mce-FNAME"><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><div class="mc-field-group size1of2"><!-- [et_pb_line_break_holder] --> <label for="mce-MMERGE3">Cellphone Number <span class="asterisk">*</span><!-- [et_pb_line_break_holder] --></label><!-- [et_pb_line_break_holder] --> <input type="text" name="MMERGE3" class="required" value="" id="mce-MMERGE3"><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><div class="mc-field-group"><!-- [et_pb_line_break_holder] --> <label for="mce-EMAIL">Email Address <span class="asterisk">*</span><!-- [et_pb_line_break_holder] --></label><!-- [et_pb_line_break_holder] --> <input type="email" value="" name="EMAIL" class="required email" id="mce-EMAIL"><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><div class="mc-field-group size1of2"><!-- [et_pb_line_break_holder] --> <label for="mce-MMERGE2-month">Birthday <span class="asterisk">*</span><!-- [et_pb_line_break_holder] --></label><!-- [et_pb_line_break_holder] --> <div class="datefield"><!-- [et_pb_line_break_holder] --> <span class="subfield monthfield"><input class="birthday required" type="text" pattern="[0-9]*" value="" placeholder="MM" size="2" maxlength="2" name="MMERGE2[month]" id="mce-MMERGE2-month"></span> / <!-- [et_pb_line_break_holder] --> <span class="subfield dayfield"><input class="birthday required" type="text" pattern="[0-9]*" value="" placeholder="DD" size="2" maxlength="2" name="MMERGE2[day]" id="mce-MMERGE2-day"></span> <!-- [et_pb_line_break_holder] --> <span class="small-meta nowrap">( mm / dd )</span><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --></div><div class="mc-field-group"><!-- [et_pb_line_break_holder] --> <label for="mce-MMERGE4">Gender <span class="asterisk">*</span><!-- [et_pb_line_break_holder] --></label><!-- [et_pb_line_break_holder] --> <select name="MMERGE4" class="required" id="mce-MMERGE4"><!-- [et_pb_line_break_holder] --> <option value=""></option><!-- [et_pb_line_break_holder] --> <option value="Male">Male</option><!-- [et_pb_line_break_holder] --><option value="Female">Female</option><!-- [et_pb_line_break_holder] --><option value="Other">Other</option><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> </select><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><div class="mc-field-group input-group"><!-- [et_pb_line_break_holder] --> <strong>Mailing list <span class="asterisk">*</span><!-- [et_pb_line_break_holder] --></strong><!-- [et_pb_line_break_holder] --> <ul><li><input type="radio" value="Yes! Sign me up to receive special deals, health tips and more." name="MMERGE5" id="mce-MMERGE5-0"><label for="mce-MMERGE5-0">Yes! Sign me up to receive special deals, health tips and more.</label></li><!-- [et_pb_line_break_holder] --><li><input type="radio" value="I agree to the competition rules" name="MMERGE5" id="mce-MMERGE5-1"><label for="mce-MMERGE5-1">I agree to the competition rules</label></li><!-- [et_pb_line_break_holder] --></ul><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><div class="mc-field-group input-group"><!-- [et_pb_line_break_holder] --> <strong>What is your health concern? You can select more than one </strong><!-- [et_pb_line_break_holder] --> <ul><li><input type="checkbox" value="1" name="group[3759][1]" id="mce-group[3759]-3759-0"><label for="mce-group[3759]-3759-0">Bladder & Kidney Health</label></li><!-- [et_pb_line_break_holder] --><li><input type="checkbox" value="2" name="group[3759][2]" id="mce-group[3759]-3759-1"><label for="mce-group[3759]-3759-1">Blood & Heart Health</label></li><!-- [et_pb_line_break_holder] --><li><input type="checkbox" value="4" name="group[3759][4]" id="mce-group[3759]-3759-2"><label for="mce-group[3759]-3759-2">Cleaning The Blood</label></li><!-- [et_pb_line_break_holder] --><li><input type="checkbox" value="8" name="group[3759][8]" id="mce-group[3759]-3759-3"><label for="mce-group[3759]-3759-3">Diabetes / Blood Sugar</label></li><!-- [et_pb_line_break_holder] --><li><input type="checkbox" value="16" name="group[3759][16]" id="mce-group[3759]-3759-4"><label for="mce-group[3759]-3759-4">Men's Sexual Health</label></li><!-- [et_pb_line_break_holder] --><li><input type="checkbox" value="32" name="group[3759][32]" id="mce-group[3759]-3759-5"><label for="mce-group[3759]-3759-5">Sore & Stiff Joints</label></li><!-- [et_pb_line_break_holder] --></ul><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --> <div id="mce-responses" class="clear"><!-- [et_pb_line_break_holder] --> <div class="response" id="mce-error-response" style="display:none"></div><!-- [et_pb_line_break_holder] --> <div class="response" id="mce-success-response" style="display:none"></div><!-- [et_pb_line_break_holder] --> </div> <!-- real people should not fill this in and expect good things - do not remove this or risk form bot signups--><!-- [et_pb_line_break_holder] --> <div style="position: absolute; left: -5000px;" aria-hidden="true"><input type="text" name="b_f8f4f82230881e41a39bdd0f1_15c66572f1" tabindex="-1" value=""></div><!-- [et_pb_line_break_holder] --> <div class="clear"><input type="submit" value="Subscribe" name="subscribe" id="mc-embedded-subscribe" class="button"></div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --></form><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><script type='text/javascript' src='//s3.amazonaws.com/downloads.mailchimp.com/js/mc-validate.js'></script><script type='text/javascript'>(function($) {window.fnames = new Array(); window.ftypes = new Array();fnames[1]='FNAME';ftypes[1]='text';fnames[3]='MMERGE3';ftypes[3]='phone';fnames[0]='EMAIL';ftypes[0]='email';fnames[2]='MMERGE2';ftypes[2]='birthday';fnames[4]='MMERGE4';ftypes[4]='dropdown';fnames[5]='MMERGE5';ftypes[5]='radio';}(jQuery));var $mcj = jQuery.noConflict(true);</script><!-- [et_pb_line_break_holder] --><!--End mc_embed_signup-->