New Client Application Form
Hi there! Please fill out this form if you are interested in becoming a client. We appreciate your patience during this time and will contact you once our practice opens up! Sincerely, Alyx Howell with Alyx Health & Wellness
Full Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
What are your health concerns? What, if any, diagnosis have you received?
Are you currently pregnant or breastfeeding?
Tell me more about yourself. What is your WHY for applying to work with me?
What medications and/or supplements are you currently taking?
What is your vision of health and wellness? In other words, what are your health goals?
What is holding you back from achieving these big goals on your own?
On a scale of 1-10, how willing are you to make the necessary dietary and lifestyle changes to progress towards your vision of health and wellness?
Is there anything else you'd like me to know about you?
*Please note that this is a Waitlist Form, and not a guaranteed spot.
The information presented on this website is intended for educational purposes only, and it hasn't been evaluated by The Food and Drug Administration. This information isn't intended to diagnose, treat, cure, or prevent any condition or disease, nor is it medical advice. One should always consult a medical professional before engaging in any dietary and/or lifestyle changes. *
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