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New client application

New client application

1. Contact information *This question is required.
This question requires a valid email address.
This question requires a valid number format.
5. How did you hear about us? *This question is required.
8. How important is your health to you? *This question is required.
9. How would you rate your dedication and willingness to make diet and lifestyle changes that will directly improve your overall health and wellbeing?
0 = no dedication, 10 = very dedicated *This question is required.
10. How easy is it for you to implement changes to your diet and lifestyle? *This question is required.
11. Do you currently have the financial resources that you can dedicate toward your health? 
The first consultation cost is $425 and the comprehensive blood test that I recommend is approximately $350+.
Please note: I do not offer insurance billing. 
*This question is required.
12. Which type of consultation package are you most interested in? *This question is required.