21 Day Liver Detox Form

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Hi! I'm thrilled you are taking this step in your health! Please fill out this form and I will be in touch with you! Detoxing should be done carefully and done right otherwise it can be more of a hindrance on your body than helpful.
By opening up the detox pathways and eliminating toxins, the body can focus more of its energy on healing and feeling well.

The detox will include:

-21 day supply of liver detox supplements by Perfect Supplements

-a binder supplement

-supplement and dietary instructions

-(2) 60 minute 1:1 coaching sessions with me. The first session must be completed before starting and the second one can be done during the detox or at the end

-ongoing support M-F via text or email throughout the program

-access to my recipe club for 21 days

The cost of the detox starts at $395. I will discuss with you what add ons may be applicable specifically to you

Optional add ons:

-enema kit and organic coffee for coffee enemas

-multivitamin ($35)

Email *

Today's date *

YYYY

phone number *

First and Last Name *

Date of Birth *

YYYY

Address to receive your detox kit at *

Why do you want to detox and what are your desired health outcomes? *

What do your work commitments look like? Other time commitments each week? *

How many hours a week are you willing to dedicate to cooking meals for yourself? *

Do you have any allergies? *

How many bowel movements do you have each day? *

l don't have a bowel movement every day

one a day

2-3 a day

more than 3 a day

Look at the Bristol stool chart and pick what your stool looks like *

Type 1

Type 2

Type 3

Type 4

Type 5

Type 6

Type 7

Alternates between constipation and diarrhea

Do you sweat when working out or sitting in the sauna *

yes

Do you have any diagnosed health conditions? *

Do you have a gallbladder? *

Yes

Are you on any medications? If so which ones? *

How much water do you drink on a daily basis? What kind is it? Tap or filtered? What kind of filter if you drink filtered. *

Do you take a multivitamin? What brand? *

Do you prefer capsules or powders (some of the supplements don't taste good) *

Capsules

Powder

What do you drink *

none

one/day

two/day

three per day

once a week

a couple times a week

Coffee (caffeinated)

Coffee (decaf)

Tea (caffeinated)

Tea (decaf)

Alcohol

Does any of the following apply to you *

Are pregnant or nursing

On hormonal birth control

Are less than 18 years of age

Have a gallbladder disorder or obstructions of the bile ducts or intestinal tract

Have active cancer

Have bipolar disorder

Have type I diabetes

Are taking anti-seizure medication, chemotherapy drugs, anti-arrhythmia meds, and/or blood thinners

Are taking any other prescription medication that requires consistent blood levels

Have an allergy to one or more of the ingredients in any supplement.

none

Required

What dates would be the best for you to complete this detox? *

Thank you for filling out this form! If there is anything else you would like me to know about your health or health goals, you can type them below.

Otherwise, you're done!

I'll be in touch to discuss whether this detox sounds like a good fit for you and the next steps!

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