New Client Form with Consultation

New Client Form w/Consultation

**Availability is first come first serve and Gary tends to book out about 2 weeks in advance (sometimes longer during peak times) for most new clients depending on availability.

Cell Phone Number *

Your Age *

*NOTE: If your voucher has expired please refer to Gary's
Voucher Reactivation program for details about your options

I have fully read the 'Mask info' section at the top of this form and agree/consent to this policy without objection *

Yes

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

1 Hour Session 90 Minute Session

Voucher/Certificate Number **NOTE: Groupon/Living Social Customers - You cannot be scheduled without your 8 digit Bar Code number *

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

Are you Pregnant? *

Yes - *Restricted services only No

Do you have any Medical conditions/ chronic problems? *

What type of session do you want? *

NOTE: Saturday appointments are reserved for regular clientele
- All New Clients must schedule Mon-Fri during posted hours before
being eligible for a Saturday time slot

Monday-Friday: Day & Time frame preferences - Check all that apply *

First Available - Anytime Early - 11am to 2pm (Mon-Fri) Mid afternoon - 2pm to 4pm (Mon-Fri) Late Afternoon - 4pm to 6pm (Mon-Thurs)

Preliminary Questions for your Consultation:

**A Full Consultation is NOT included with Groupon/Living Social Vouchers. All Consultations must be prepaid before scheduling. Keep in mind a Full Consultation will add an extra 2 hours for your session - please keep this in mind when scheduling.

I understand that a Full Consultation is not included with Groupon/Living Social vouchers. I am requesting this service and that you bill me so that I may pay for it in advance prior to getting scheduled. *

Yes - please bill me I have already prepaid for a Full 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: *

New Client Form w/Consultation

Preliminary Questions for your Consultation:

General Info

Gary's Services

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