Please note that this is a 7-page form and can take upwards of 1 hour to complete, and it is best (easiest) done on a desktop computer (vs. mobile device). In the event you need to stop and complete the form later, click on the Save button to save your progress, so that you can come back to it later. Once completed (& Submitted), your information is automatically saved and forwarded to our secure, online database (incl. any pictures &/or documents that you upload to this form). Please do not re-submit this form, even if it produces an error. In the event that you receive an error, please contact our office at: (678) 466-9736.
As you fill this form out, please be honest. The information you provide within this form is never shared with anyone outside of the coach(es) / consultants you are assigned to within our office, unless by court order or your documented consent; and while not every data transmission is sent over HIPAA servers &/or emails, we value the security of your data, so we ensure that, once received (via this form, email, or etc.) it is stored on a highly encrypted, cloud-based server. We can only help and serve you best if we have the most complete and detailed information on your current health, lifestyle, and circumstances.
Before (or at the start) of your first appointment, you will be required to pay a
non-refundable deposit, which will be deducted from your Client Registration bill. In addition, it is the policy of Prime Wellness USA to have at least one credit or debit card on file in the event of a late cancellation or no-show. We will request this information (e.g. a credit or debit card) when you create your first appointment.
NOTE that we are NOT a healthcare or medical practitioner / office and all of our services are strictly advisory information related to diet, lifestyle, &/or health, and NOT intended to treat, diagnose, or cure any disease. For more information, please review our Terms, Conditions, and Disclaimers; or visit www.PrimeWellnessUSA.com, scroll to the bottom of the page, and click "Terms, Conditions, & Disclaimers". By signing below, and continuing with this registration form, you attest that you've read &/or agree with our Terms, Conditions, and Disclaimers.
Thank you for choosing Prime Wellness USA as your health and wellness provider. We look forward to serving you!