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Client Questionnaire
Note: It is important for us to know your laboratory values so we can monitor your progress as you build your health. It is recommended that you obtain this information from your physician for your own knowledge and records.

PRELIMINARY DIETARY ANALYSIS FOR ENERGY EVALUATION

                                                Waiver

Holistic Choices works cooperatively as a professional courtesy with the medical community in the spirit of integrative health and cooperation of all health disciplines to provide you with the best possible, informed health options.

Holistic Choices’ professional status is that of teacher of healthful living and not that of medical doctor. It is advocated that you involve your physician while implementing any alternative or wellness program to use precaution and be made aware of any contraindications; however, it is your Constitutional right to decline this recommendation.

If you choose to decline to inform your physician, it is essential you provide accurate information about your medications and your current dietary habits to the nutritionist. This prevents possible problems such as adverse drug-nutrient interactions that can affect the drug’s performance or hazardously increase its actions.Some drugs can block nutrient absorption while some nutrients can affect a drug’s desired effect.

I have sought the services of Holistic Choices, Mary Esther Gilbert, Holistic Nutritionist. I hereby certify that all of the information I have completed on this form is, to the best of my knowledge, true and correct.

Fee:

 

The normal consultation fee is $197 for 2-3 hours, and includes a complete individual nutritional healing protocol provided to the client in eBook form, which will be discussed in detail at the consultation session.

 

A discounted consultation fee of $129 is available to certain associates (and their referrals) of various companies for which I am a product educator and consultant.

A $65 deposit is required for the analysis/assessment and preparing your nutritional health improvement protocol in eBook form, at least 3 days prior to your consultation appointment date.

Consultation By Appointment

Please indicate what day/s and time/s you are available for your consultation. Please allow 2-3 hours for your comprehensive consultation.

Which days are you available?

Thank you for completing this important questionnaire. Mary Esther will be contacting you within 24-48 hours to schedule your consultation appointment.

Thank you for submitting your confidential information. Mary Esther will contact your for your appointment within 24-48 hours.

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