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Genuine Wellness Application
Current client load is near capacity with limited availability. Please fill out this application to see if you qualify for a spot. You will be contacted via email or text for next steps.
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Email
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Your email
Option 1
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Name
Your answer
DOB
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Phone number
Your answer
Who referred you?
Your answer
How many medications are you taking?
Zero
1 or 2
3 or more
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Do you take supplements?
Yes
No
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Are you willing to remove Gluten and Dairy from your diet?
Yes
No
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How many covid vaccines have you had?
Zero
One
Two
3 or more
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Have you ever worked with a holistic practitioner?
Yes
No
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Do you have a current diagnosis? Please list if so
Your answer
Please list your top 3 health goals?
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