cleanse sign up form & waiver: name * First Name Last Name select a cleanse cycle: * july 22-24 3-day – $600 aug 4-6 3-day – $600 phone * (###) ### #### address Address 1 Address 2 City State/Province Zip/Postal Code Country email * preferred way to be contacted: whatsapp text email phone do you have children? if yes, how many & what ages: would you like to be part of our small community—receive group texts & emails? yes no list the top three goals you want to achieve with this cleanse: your current height and weight: your ideal / dream weight: please list any medications you currently take: please list any injuries you have, or have had that are noteworthy: please list any health concerns you have: have you ever done a cleanse before? if yes, which one(s)? are you currently practicing intermittent fasting? if yes, which meals do you skip? do you typically have breakfast? yes no if yes, what do you typically have? do you have any food allergies? are you vegan? yes no do you have any other dietary restrictions? will you have time to rest during this cleanse? yes no will you have time to prepare your own simple meals daily? yes no are you interested in the following enhanced services: check all that apply: functional medicine nutritionist hormonal testing iv treatments yoga pilates meditation colon therapy lymphatic drainage massage / body work acupuncture cranio sacral cryotherapy infrared sauna the services provided by us do not contain or constitute, and should not be interpreted as, medical advice or opinion. you are urged and advised to seek the advice of a physician or a medical professional with any questions you may have regarding your health before beginning our program, especially if you are being treated for an illness, taking prescription medication or following a therapeutic diet to treat a disease. if any information you receive or obtain from us is inconsistent with the medical advice from your physician, you should follow the advice of your physician. electronic signature: * date * MM DD YYYY thank you!
