Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Phone *

(###)

###

####

Reason(s) for doing juice cleanse *

General health

Weight loss

Clear skin

Detox

Gut healing

Other

Do any of these apply to you? *

I currently have or have a history of

Eating disorder

Depression / anxiety

Gallstones

Weight loss

Cancer

Diabetes

Constipation

Low blood pressure (less than 100/50 mmHg)

Alcoholism

I drink coffee or other caffeinated beverages

I understand that results are not guaranteed *

Yes

I understand that I should consult with my medical doctor to discuss adjustment to medications, particularly diabetes medications, prior to starting a 3-day juice cleanse *

Yes

I understand that I may experience side effects such as but not limited to: headache, breakouts on my skin, weakness, nausea, change in bowel movements, hunger, weight loss *

Yes

I understand that it is highly recommended that I attend the orientation session *

Yes