HTMA Reset Intake Form

AUGUSTA Naturopathy

HTMA Reset: 12-Week Program
HTMA Reset Intake & Booking Form

Complete this form to reserve your spot in the 12-week HTMA Reset program. Once submitted, you'll receive your test kit by mail and your onboarding instructions via email.
Full Name
Email Address
example@example.com
Phone Number
Mailing Address for HTMA kit delivery
Date of Birth

MonthDayYear
Date
What are your top 3 health concerns or symptoms right now?
When did these symptoms begin?
What brand and type of shampoo (and any other hair products) do you use?
Have you done any recent lab work?

Yes *If yes, please upload the report below.No
File Upload

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Are you taking any medications?

YesNo
If yes, please list:
Are you taking any supplements, herbs, or homeopathics?

YesNo
If yes, please list:
Please list any known allergies or sensitivities to food, medications, or supplements.
Do you follow any specific dietary preferences or restrictions?

Gluten freeDairy freeVegetarianPescatarianLow CarbVeganPaleoHalalKosherOther
How would you describe your energy levels most days?

ExcellentGoodFairPoor
How would you describe your sleep?

RefreshingInterruptedTrouble falling asleepTrouble staying asleepSleep? What is sleep??
How often do you experience stress?

RarelyOccasionallyFrequentlyConstantly
Do you drink caffeine?

YesNo
If yes, what kind, how much, and how often?
Do you drink alcohol?

YesNo
If yes, how much, and how often?
Do you smoke or use nicotine products?

YesNo
What are you hoping to gain from this program?
Have you worked with a naturopath or functional provider before?

YesNo
Is there anything you want me to know about your health journey?
Women's Health (only if applicable)
Are you currently pregnant?

YesNo
Are you currently breastfeeding/pumping?

YesNo
Are your menstrual cycles regular?

YesNoN/A
If your cycles are not regular, please describe.
Do you have a history of PCOS, Endometriosis, Thyroid Disorder/Imbalance, or a Hormonal Condition?

YesNo
If yes, please describe.
Booking and Consent

Program Cost: $425 Includes: HTMA kit & lab, personalized supplement protocol, video review, weekly group support, and monthly check-ins.

Cancellation/Refund Policy: Because this program involves lab test ordering and personalized analysis, all sales are final once your kit has been mailed.

I understand and agree to the terms above.

I acknowledge that this program does not replace medical care and is for educational and wellness purposes only.
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AUGUSTA Naturopathy