Intake Form

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityProvince

Postal Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Please list your medications (Doses are not required)*

The following are EXCLUSION criteria to the program. This program is not safe or appropriate for you if have any of the following:

a strong desire and priority on fast weight loss with whatever it takes
unstable mood or other psychiatric disorder

EATING DISORDER

restrictive eating disorder (anorexia nervosa, bulemia nervosa)
active Binge Eating Disorder (e,g, eating large quantity of food in a discrete period of time with the sense of lack of control)

if not sure, you can do a BED self-assessment at mybinge.ca

HEALTH

poorly controlled medical conditions that require close fluid and salt monitoring or blood sugar monitoring (Congestive Heart Failure, controlled Diabetes Mellitus, Advanced kidney disease)

SUBSTANCE USE DISORDER

Substance Use Alcohol

I drink more than 9 drinks a week or 2 drinks a day most days (women);
I drink more than 14 drinks a day, more than 3 drinks a day most days (men);
(drink + 12 oz beer, 5 oz wine, 1.5 oz distilled alcohol, 12 oz cider)
Substance Use THC| I regulalry use cannabis with THC.
Substance Use OTHER| I engage in recreational drug use that impairs my judgement with respect to eating.

CONTACT YOUR HEALTHCARE PROVIDER IF YOU ARE IN NEED OF CARE FOR ANY OF THE ABOVE. THIS IS NOT A MEDICAL PROGRAM.

I am safe to proceed with the program. I do not have any of the exclusion criteria.*

YesNoI'm not sure.

I am safe to proceed with the program. I do not have any of the exclusion criteria.*

YesNoI'm not sure.

If you are not sure, please provide more detail. We may contact you for further clarification.

What is your current level of physical activity?*

Do you eat in a vegan or vegetarian style?*

yes - veganyes - vegetarianno

Registration Level

Premium at $1995 +HSTConcierge at $4495 + HST

I understand that payment in full is required and there is a NO REFUND policy. Payment will be sent via e-transfer to angiehongmd.com. Due to e-transfer limitations, payments greater than $3000 may have to be deposited in two sums.*

Yes

Signature*