Consultation Form

NAME*

First Last

ADDRESS*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

GENDER (How do you identify?)*

DATE OF BIRTH*

PHONE*

EMAIL*

EMERGENCY CONTACT (First Name, Last Name, & Phone Number)*

HOW MANY TIMES PER WEEK ARE YOU PHYSICALLY ACTIVE?

WHICH TYPES OF ACTIVITIES?

HOW MANY OUNCES OF WATER DO YOU DRINK DAILY?

WHAT TYPE OF WATER DO YOU DRINK DAILY?

HOW MANY DIGESTIVE ENZYMES DAILY?

HOW MANY BREATHING EXERCISES DAILY?

WHICH DO YOU CONSUME DAILY?

WHAT TYPE OF FOODS DO YOU CRAVE?

Salty

Chocolate

Sweets

Breads

Other

WHAT ARE YOUR FAVORITE FOODS?

HOW MUCH DAILY ENERGY?

WHAT SURGERIES HAVE YOU HAD AND WHEN?

HOW MANY HOURS OF TV DO YOU WATCH DAILY / WEEKLY?

HOW MANY HOURS OF SPIRITUAL ENRICHMENT EACH WEEK? (Prayer, Meditation, etc.)

HOW MANY HOURS A WEEK DO YOU SPEND WITH FAMILY / FRIENDS?

HOW MANY HOURS OF SLEEP DO YOU GET EACH NIGHT? HOW MANY DO YOU NEED?

WHAT PRESCRIPTION MEDICATION(S) DO YOU TAKE?

DO YOU HAVE ANY KNOWN ALLERGIES?

AREAS OF CONCERN

DISCLAIMER*

The client fully understands that the offered alternative treatment is to aid in managing health concerns. The client has requested alternative therapies from "The Pure Rx."

The client understands that alternative treatment does not replace any medical treatments they are currently undergoing. It is also recommended by "The Pure Rx" that all current medical treatments for any health concerns should continue to be followed up by their existing healthcare provider.

The client understands that alternative treatment does not cure medical conditions, illnesses, or injuries but offers to aid in relieving symptoms.

The client understands they will have no guarantees concerning benefits or results that may or may not occur by using natural treatments.

The client understands that "The Pure Rx" is not liable for any missed or failed medical diagnosis, treatments, or care of any illness, disorder, disease, or condition clients may suffer during treatment.

I understand and agree to a 48-hour cancellation policy. Appointments canceled within 48 hours will accrue a $50 fee, and I agree that a no-call and no-show will accrue the entire consultation fee.

I understand that Dr. Mathew Jadan is only providing a nutritional consultation.

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Cancer – Digestion – Fatigue – Sleep Apnea – Sickle Cell Anemia – Other Conditions