New client intake form

Claim your health back

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Welcome! 😊

Please complete this form so we can review your case before working together.

Instructions 📝

📧 Please provide your personal details and briefly explain the reason for your consultation. Make sure your email address is correct so we can contact you.

👩🏻‍💻 Once your form has been reviewed, we will contact you to schedule your consultation as soon as possible.
Email*
example@example.com
First name and last name*

First NameLast Name
Age*
Occupation
Dejar en blanco si se trata de una consulta para niños con el programa HTMA Kids.
Sex*

MaleFemale
City and country of residence*
What symptoms are you currently experiencing, and why do you feel I am the right practitioner to support you?*
Please be as detailed as possible.
How did you find me?*

InstagramTikTokTwitter/XPodcastRecommendation from a friend or relativeGoogleChatGPTOther
Do you know what Mineral Balancing is?*

Yes, I have done it before with another practitioner or have researched it.I have heard about it.No.
What is your current diet like?*
Please be as detailed as possible.
Please list your current supplements and medications, including daily doses.*
Important: We do not work with individuals with active eating disorders, diabetes, oncology patients, individuals with alcohol or drug addictions, or those experiencing *severe* adverse effects from vaccinations.

By completing and submitting this form, you confirm that you do not fall into any of the categories listed above and that you accept our Terms and Conditions.
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Claim your health back