Medical Intake Form | Eternelle Health & Wellness

1
What is your first and last name?* This field is required.
First Name
Last Name
2
What is your phone number?* This field is required.
Please enter a valid phone number.
3
What is your email?* This field is required.
example@example.com
4
Just to be safe—do you have any of the following?Select all that apply. Skip to the next question if none apply.
Kidney or liver issues
Allergies to any ingredients in the product
Iron overload
B12-related anemia
Active cancer
On blood thinners
Pregnancy & breastfeeding
5
Thank you for your honesty. This product may not be safe for you.Please check with your doctor first.
I understand
Go back
6
Is there anything else about your health that we should know before you take this product?Leave blank if none
7
Image Field
8
All set! Just sign below to confirm and we’ll take it from here! Thank you. * This field is required.
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