Consultation Form & Lifestyle Survey

1
Name* This field is required.
First Name
Last Name
2
Phone Number* This field is required.
Area Code
Phone Number
3
Email* This field is required.
example@example.com
4
Are you 18 years old or older?* This field is required.
YESNO
5
Where are you from?* This field is required.
6
Have you or someone in your household shopped online within the last year?* This field is required.
YESNO
7
Do you consider yourself open-minded to new things?* This field is required.
1
2
3
4
5
I don't like change
Very open-minded
8
How important is it to live a healthy lifestyle?* This field is required.
1
2
3
4
5
Not important at all
Extremely important
9
What type of areas would you like to improve in your life or the life of a loved one? Select all that apply.* This field is required.
Physical (weight loss, blood pressure, cholesterol, A1C numbers, Diabetes, Asthma, Eczema, Acne, Memory, Energy, Bone & Joint, Anemic, etc.)
Personal (Balance, Time Freedom, Less Stress, Peace of Mind)
Environmental (Less Toxin & Chemicals, Clean Home & Environment, Safer Products)
Financial (Pay off Bills, No Financial Worries, Income to Travel, Savings for Retirement and Family)
10
What are your urgent health goals?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
11
What stores do you usually shop at for food, snacks, vitamins/supplements, personal hygiene products & household products?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
12
How often do you shop each month for food, snacks, vitamins/supplements, personal hygiene product & household products (cleaning products, toothpaste, lotion, cosmetics, snacks, etc.)?* This field is required.
1-2 times a month
3-4 times per month
5 or more times a month
13
What is your monthly budget for food, snacks, vitamins/supplements, personal hygiene products & household products (cleaning products, toothpaste, lotion, cosmetics, snacks, etc.)?* This field is required.
Less than $50 a month
$50-$100 a month
$150 or more a month
I don't know, I don't have a monthly budget
14
Do you use any of the services listed below? Select all that apply.* This field is required.
Grub Hub
Instacart
Walmart/Sams or Target Pickup
Subscription Boxes
Waiter
Uber or Lyft
Hello Fresh
Grove Collaborative
Blue Apron
Shipt
Amazon Prime
PeaPod
Amazon Fresh
Other
15
What are some of the reasons you would shop at a different store for your food, snacks, vitamins/supplements, personal hygiene products & household products (cleaning products, toothpaste, lotion, cosmetics, etc.)? Select all that apply.* This field is required.
Free Products & Gifts
Products that are higher quality and safer for your home especially children
Save Time/ Save Money
Customer Perks like a referral or affiliate program
Pays customers to learn about products and shop
Convenient online shopping, my products are delivered to me
Other
16
Schedule an Appointment* This field is required.30-minute Individual Appointment using Virtual Zoom
Should be Empty: