Health Intake Form

Health Assessment & Consultation Includes: 

• In-depth health questionnaire  
• Dedicated health and wellness consult (60 minutes) 
• Interpretation of and recommendations pertaining to our evaluation of the health intake form and other data received 
• Personalized 90-day health and wellness plan of care 
• Nutritional, herbal, and supplemental therapies tailored to your condition 
• Juice therapies tailored to your condition 
• Lifestyle and exercise therapy recommendations 

Consultations generally last 60 minutes for a non-refundable fee of $75.00 which is to be paid upon the completion of this form. You will receive check-in calls from our office, but 30-day check-in appointments are recommended for ongoing support and wellness. Monthly follow-up appointments to monitor progress are $45 for 20 minutes. All other costs associated with our 90-day programs are for the purchase of recommended supplements, herbal formulas, and produce. A 90-day cost determination will be provided once your program has been finalized.

Consent, Disclosure & Disclaimer: Congratulations for taking this important step toward creating a healthier life for yourself! This health intake form is intended for educational purposes only, to assist individuals in learning how to preserve their own health. It is not the intention of this evaluation to diagnose or to prescribe any medication, treatment or modality for any physical or mental disorder, disease, ailment, complaint or anomaly. Therefore, any use of the information obtained from this health intake form, is at the sole discretion of, and in response to the direct request made by the individual whose name is signed on this form.