Client Form

Client Intake Form

Full Name*

Date of Birth/Age

Mailing Address

Phone

City/State/Zip

Preferred Contact Method

Phone Email

How did you hear about us?

What is the primary purpose of your visit?

Do you have any current health concerns?

Describe any recent (last 90 days) illnesses, emotional stresses, out of ordinary health experiences.

Have you had any travel in the last 90 days?

What is your goal in completing the Hair Analysis?

List any current medications and/or supplements.

Would you like to receive text or email messages with upcoming specials or events?

Client Signature

Test/Retest Package Purchased?

Yes No

Retest Date

Supplements or Other Recommendations

Other Notes: