Detox Registration

1

What is your name?* This field is required.

First Name

Last Name

2

What is your birth date: year, month, day?* This field is required.

Year/Month/Day

3

What is your gender?* This field is required.

4

What is your email address?* This field is required.

example@example.com

5

What is your phone number?* This field is required.

Area Code

Phone Number

6

How would you prefer me to contact you?* This field is required.

7

How did you hear about my detox program?* This field is required.

8

Which Detox level are you registering for?* This field is required.

To find out what each level consist of please visit my website here https://www.fromtherootsholistic.ca/detox-with-a-nutritionist.html

9

The Advance program requires supplements & botanicals remedies. You have the option to purchase the required supplements on your own, however please be advised that the supplements have to be the specific brand name listed and are needed for the detox. If you would like to order through me please choose which supplements & botanicals you would like, this will be added to your base fee of $100.00. All prices include taxes. LIMITED QUANTITIES IN STOCK FIRST COME FIRST SERVE.

2 bottles of Liver Health Tincture, Orange Naturals $35.40 (average retail price for 2 bottles is $43.98- $47.98 in Health Food stores)

Bulklax® , St-Francis Herb Farm $17.94 (average retail price is approx. $22.95 in Health Food stores)

Oréganum Plus® 1:3, St-Francis Herb Farm $11.94 (average retail price is approx. $16.94 in health food stores)

Oréganum Plus® Gel Caps, St-Francis Herb Farm $16.74 (recommended for those who can't tolerate the taste of oregano oil, average retail price is approx. $22.99 in Health Food stores)

Probiotics, CanPrev, $22.12 (average retail price is approx. $25.99-$29.99 in Health Food stores)

10

List all medications, including supplements, sports supplements, herbal remedies, birth control, IUD's... Also please list any underlying medical conditions.This information is required to be sure there are no contraindications with any of the herbs and supplements recommended during the detox.

11

Health Concerns and or goals: List goals or health imbalances you would like to work on?* This field is required.Please be sure they are relevant to the service or program you have registered for.

12

If you have any allergies or sensitivities please list them below.

13

Wellness Program Terms & Conditions (please read)

All information provided in this form and going forward is confidential and will not be released to anyone.
Information provided during the program does not take into account all individual conditions and may therefore not be advisable or beneficial to all participants.
Dana Clark/From the Roots Holistic is not liable for misuse, misunderstanding, injury or health issues that may ensue from the information provided during the program.
Information provided by Dana is in accordance with her formal academic training, continued education, and science-based research.
For Health Benefit Claims, you are encouraged to inquire and confirm that you are covered for my services (Registered Nutritional Consultant and/or Certified Natural Health Practitioner) and to submit receipts to your insurance company.
All fees are non refundable.

14

By signing this form you are agreeing to all the Wellness Program Terms & Conditions

Clear

15

How would you like to pay for your appointment or program?* This field is required.

E-transfer to fromtherootsholistic@gmail.com

Credit card

16

Do you require a formal receipt to submit to any Health Benefits Coverage Plan?* This field is required.

yes

no