Wellness Program 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 the program you are registering for?* This field is required.

Zen Fitness/Jenn

From the Roots Holistic/Dana

Friend

8

What program are you registering for?* This field is required.All Wellness Programs will be held online until further notice

9

Will you be doing this program with a friend/family member?* This field is required.

Yes (be sure to have them register as well)

No

10

What is your friends/family members name?* This field is required.Be sure to have them fill out this form as well.

First Name

Last Name

11

Would you like to add on any extra services to compliment your program?If you are not interested in add ons just hit next

Cooking class (service temporarily suspended)

Nutritionist guided shopping trip (service temporarily suspended)

Detox

Follow up mini sessions

12

How many mini sessions would you like to include?

15 minutes each

13

How would you like to have your appointment/sessions?* This field is required.

Online via Facebook, Hangouts, or Skype

Over the phone

14

What Detox session are you registering for?* This field is required.

Private one on one (starts anytime)

May 18, 2020

15

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

16

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)

17

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.

18

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.

19

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

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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.
For online sessions, it is recommended you avoid using mobile data & satellite connections as they don’t provide the quality connection needed for video calls.
For the Foundations to Wellness program, once your appointment is booked, it is your responsibility to attend this appointment and any future appointments or cancel within 24 hrs. No-shows will be billed $10 for not canceling the appointment(s). Please arrive on time for appointments, should you arrive late your appointment will still end at its original intended time.
Payment plans are available, a $100 downpayment is required as well as a credit card on file. Should you drop out of any program at any time all payment must be honored and the full fee paid.
All fees are none refundable.

21

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

Clear

22

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

Cash (for in person appointments only, please bring the exact amount)

E-transfer to fromtherootsholistic@gmail.com

Credit card

Payment Plan

23

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

yes

no