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
What are your top 5 health concerns?*
What interests you about the HTMA test?
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)
For your consultation, do you prefer a virtual meeting or a recorded video review? (Video review requires a 20 minute onboarding call to review symptoms and concerns)*

Virtual meetingRecorded video
Which package are you applying for?*

Foundational Wellness (includes HTMA)Comprehensive Wellness (HTMA + Blood Chemistry)
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 to 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 :)
Should be Empty:

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