Clone of Biocore Custom Supplement Order Form

Health Consultation Intake Form

Please fill in this form as fully as possible to get the maximum benefit from your consultation. Your information is confidential and will never be shared with any third party.
Your Details:

First NameLast Name
Email
Phone Number
Please enter a valid South African mobile numberFormat: (000) 000-0000.
Shipping Address if ordering supplements:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age
Occupation
Gender
Special Considerations:
Height
Your height in m/cm
Weight
Your weight in kg
ALLERGIES: Any allergies to foods, medications, supplements or substances? Please list and describe them.
MEDICATIONS: On any medications, prescription or over the counter? Please list them, the dosage and how long used. If a medication has been taken for a long time, but stopped, please describe.
SUPPLEMENTS: Taking any health supplements currently? Please list them and the dosage, and what they are being taken for:
SURGERIES/INJURIES: Still recovering? What happened and how long ago was it?
DIAGNOSES: Diagnosed with, or has, any illness, disease, disability, problem which needs to be supported?
Health goals for this supplement:
Fitness and strength: Check all which apply to you
What happens next?
After clicking submit, please allow 24 hours for a response. Remember to check your spam and promotions folders!

We will include a link for secure payment. (R450)

After payment reflects, we will arrange a time slot for your 60 minute consultation via Whatsapp or Google Hangouts.

PLEASE NOTE, THIS IS NOT A MEDICAL CONSULTATION, YOU CAN NOT CLAIM FROM YOUR MEDICAL AID, NO DIAGNOSIS OR PRESCRIPTIONS CAN BE GIVEN.

This is a guided exploration of the general picture of your health, to determine which foods, supplements, herbs, therapies or lifestyle changes might best support you on your individual health journey, alongside any medical treatments. Sumbission of this form means you have read and understood.
By clicking SUBMIT, you acknowledge that you are in charge of your health and wellbeing at all times. Should you experience any negative health event or medical emergency, you will promptly get medical attention from an appropriate care provider.

If you need to save and come back later, click save.
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Health Consultation Intake Form

What happens next?