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  • Client Nutrition & Wellness Intake Form

    Please provide your information to help us understand your health and wellness needs. All responses are confidential.
    • Personal Information 
    • Nutritional Data 
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    • Meal Timing & Habits 
    • Movement & Activity 
    • Sleep 
    • Eliminations 
    • Females Health (if applicable) 
    • Supplements & Medications 
    • Medical & Holistic History 
    • Holistic Modalities Familiarity 
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    • Consent & Acknowledgement 
    • Client Consent & Disclosure Form

      I understand that the services provided to me by A Plus NutriPro, including nutritional education, holistic wellness guidance, lifestyle support, and reflexology sessions, are intended solely to promote general well-being and support my natural health. I acknowledge that these services are educational in nature and should not be used as a substitute for medical care.

      I understand and agree to the following:

      Non-Medical Services:
      I fully understand that the practitioner at A Plus NutriPro is not a medical doctor, does not diagnose, treat, or cure medical conditions, and does not prescribe medications or medical treatments.
      Any information I receive regarding nutrition, supplements, herbs, lifestyle practices, or reflexology is for general wellness purposes only.
      Purpose of Services:
      The services provided are limited to holistic wellness consultation, nutritional education, lifestyle guidance, and reflexology techniques intended to support relaxation, stress reduction, and overall well-being. These services are not intended to be presented as medical or psychological care.
      Client Responsibility:
      I understand it is my responsibility to consult a licensed physician or qualified healthcare provider for any medical concerns, diagnoses, emergencies, or treatment needs. I will inform my primary healthcare provider of any supplements or wellness practices I choose to adopt.
      No Agency or Investigative Capacity:
      I state that I am not, during this visit or any subsequent visit, acting as an agent for any federal, state, or local agency, nor am I participating in any form of investigation or entrapment.
      Reflexology Informed Consent:
      I understand that reflexology involves applying pressure to specific areas of the feet, hands, or ears to promote relaxation and overall wellness. Reflexology does not diagnose or treat medical conditions, and any benefits experienced are supportive and complementary in nature.
      I understand that it is normal to experience mild tenderness or slight discomfort during or after a reflexology session, and these sensations typically resolve within a short period. I will inform the practitioner of any pain, discomfort, medical conditions, or contraindications prior to the session.

      By signing below, I confirm that I have read, understood, and agree to the terms of this disclosure and consent form. I agree to the terms outlined above.

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