Application Form

Application Form

Thank you for your interest in working with me! If you haven't already, please review my services page here: www.torisauernutrition.com/services prior to submitting this application. Please note I currently only work with clients in the US due to testing and supplement availability. Additionally, blood chemistry testing is not available in New York and New Jersey. Please look out for an email from me once your application has been submitted. If you have any questions feel free to reach out to me directly: tori@torisauernutrition.com
Name*

First NameLast Name
Email*
example@example.com
Phone Number
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you currently live in the US?*

YesNo
Which service are you applying for?*

Intro to WellnessFoundational Wellness (HTMA)Comprehensive Wellness (HTMA + Blood Chemistry)
What are your top 5 health concerns?*
Do you prefer a virtual consultation or a recorded video review?*

Virtual meetingRecorded videoUndecided
Would you like to add any additional support elements?

I would like to add on a custom recipe bookI would like to add on a 30 day meal planI'm unsure and would like to learn more during our sessionI am not interested in any of the add on options
What else would you like to share before we get started?
An in depth symptom analysis and intake form will be sent to you following this application, so don't stress about including every detail here. Share as much or as little as you would like to get started :)
Foundational and Comprehensive Wellness packages, please answer the following questions
When was the last time you dyed your hair?

I dyed it less than a month ago1 month ago2-3 months agoI don't dye my hair
What type of shampoo do you use?
Would you prefer to take your own hair sample or have me take it for you? (location and availability permitting, no additional cost)

I will take my own sample with help from another personI would like you to collect my sample (limited to northern VA)
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Application Form

Foundational and Comprehensive Wellness packages, please answer the following questions