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First & Last Name

Age

Phone

Tell us about your main health complaint

Example: How long has it been an issue? How often does it bother you?

What do you expect to achieve working with us?

BioFunctional Nutrition is an opt-in model of self-care that will require money, time, and commitment. On a scale of 1-10, how committed are you to achieving your goals?

You acknowledge that the information you provide, including personal details, health history, and contact information, may be considered Protected Health Information (PHI) and Personally Identifiable Information (PII). By proceeding, you consent to the use and sharing of this information as necessary for the provision of our services.

You acknowledge that as a health coach business, BioFunctional Nutrition, along with its employees, contractors, and representatives, may not fall under HIPAA regulations. While we are committed to protecting your PII and PHI, we cannot guarantee full compliance with HIPAA standards. Please note that results from these services may vary.

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By submitting this form, I attest the information provided is accurate.