Your Wellness Plan - Interest Form
Please read the form fully before submitting. Only complete this form if you'd like to move forward with a 1-on-1 wellness coaching plan with John!

For more details on the plan, please read the details here:

Information you supply here is only used by me for the intended purpose of wellness coaching. The 45-day coaching plan begins once your intake form is completed and payment is made. Your journal should arrive within 14 business days (sorry, it's personalized so take some time) for plan initiation if you do the "all-in" plan.

PLEASE NOTE: I am not a medical professional and therefore may not be able to coach you if you have certain dietary restrictions or physical conditions. We can discuss your situation before you pay and complete the onboarding process for the plan.

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What is your first name?
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What is your last name?
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What is your date of birth?
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MM
/
DD
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YYYY
What is your email address?
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What is your cell (mobile) phone number?
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What is your gender?
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Are you using any other diet/wellness programs or methodologies?
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Check all that apply
Required
Do you have any medically necessary dietary restrictions or conditions that could impact your nutrition?
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Check all that apply
Required
WAIVER & DISCLAIMER
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By submitting this form, and selecting "YES AND AGREED" below, I attest to being a generally healthy adult with clearance from my doctor, or similarly qualified medical professional, to undertake and participate in a diet, activity and wellness program such as this. I understand and agree that all nutrition and dietary guidance are suggestions only and must be reviewed with my doctor, registered dietician or similarly qualified professional. I understand and agree to seek medical clearance to participate in any physical activities or exercises that maybe suggested during the course of the engagement. I understand and agree to hold John harmless against any and all damages, regardless of type, scope or source, resulting from participation in this wellness coaching or resulting from any dietary, activity or related suggestions.
Enter your initials below, as a form of electronic acknowledgement and acceptance of the WAIVER & DISCLAIMER above.
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Is there anything else you wish to make me aware of at this point? There will be a more detailed intake process later.
Which payment method works for you?
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Submit
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