New Client Form with Consultation

**This New Client form is for anyone requesting an appointment with Gary for the first time that requires a Full Consultation. Please take the time to fill out this form completely.

New Client Form w/Consultation

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Your Age *

Do you have a Gift Certificate or Voucher *

If you purchased from Groupon/Living Social or Gary's New Client Offer which option did you buy? *

1 Hour Session 90 Minute Session

Full Name of Person who purchased your Certificate or Voucher *

Voucher/Certificate Number **NOTE: Groupon/Living Social Customers - You cannot be scheduled without this number *

Full name of your Referral (Type N/A if you do not have one) *

Are you Pregnant? *

Yes No

Do you have any Medical conditions/ chronic problems? *

What type of session do you want? *

Do you prefer a specific day or time of day? Check all that apply *

Please request specific dates/times here: *

Additional requests, comments or questions here: *

Preliminary Questions for your Consultation:

1. Do you have a specific goal in mind for your Consultation? (examples: Eliminating chronic pain, Getting off of my medications, etc.) *

2. List all Medications by name that you are on and what they are prescribed for: (example: Lexapro – For Anxiety) *

3. What nutritional supplements do you take? (example: Multi-vitamin/Mineral, Vitamin D, C, Specific herbs etc.) *

4. What does your diet generally consist of? (example: Conventionally grown food, Organic Food, Fast foods? Or combination of all 3?) *

5. Do you have any sleep issues? How often do you wake up fully rested and refreshed? (example: 25% of the time, 50% of the time, 75% of time, etc...) *

6. Do you get at least 4 standard size (16.9 oz) bottles of water everyday? *

7. If you are trying to alleviate any specific issues with your health what are they and are any of these issues debilitating or limit you in any way? *

8. How often do you get massaged, or get alternative treatments such as reflexology, energy healing etc. *

9. List anything else that may be of importance to your consultation here: *

Submit

New Client Form w/Consultation

Preliminary Questions for your Consultation:

General Info

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