New Customer Registration Form

New Customer Registration Form:

Completing this form will allow us to contact you with a practitioner recommendation and consult options. Thank you for providing your details, they are kept in complete confidentiality and will not be used for any marketing purpose without your consent.
Full Name*

First NameLast Name
Your age
Phone Number*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
example@example.com
How did you hear about us?
Please list your key health concerns/symptoms that you need to address:
Do you follow a vegan diet that you will not deviate from? (please note, Maria does not work with vegan clients, book in with Eliza or Elizabeth on my team)
Please state YES or NO
How severe are your current symptoms (score between 1-10, ten being extremely severe)
Have you already seen other health practitioners to help with these issue(s)? Eg: GP, integrative GP, chiropractor, nutritionist, dietician, naturopath, psychologist, hypnotherapist, kinesiologist, etc)
Have you already done functional medicine testing, blood testing or any other investigations? (eg: Gut tests, Pyrrole test, Hair analysis, Blood tests, etc)
What are your current health conditions or what have you been diagnosed with?
Are you willing to 'do whatever it takes' to achieve your goals? Please score between 1 to 10 (1 = I'm not really willing to change much.....10= I will do whatever it takes)
Please rate your current stress level

1

2

3

4

5

1 is Not stressed, 5 is Highly stressed
Thank you for completing this form. We will be in touch within 48h with a practitioner and session time recommendation.

Kind regards

Maria Allerton, Clinic Director
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New Customer Registration Form: