Form – HPQ Revisit Form

September 19, 2016
4:03 am

Step 1 of 2

Please complete this form in one sitting. Incomplete forms cannot be saved.
Name*
First Last
Date of Birth*
Month
Day
Year
Today's Date*
Month
Day
Year
1. Keep your appointments. Your success depends on our ability to keep you motivated, handle obstacles and chart your progress! If you must re-schedule, give us plenty of notice (24 hours). It is ultimately your responsibility to stay on course with your personal program.
I have read the preceeding paragraph and I fully understand the policy.*
- Yes
2. Drink plenty of water (always) and avoid sweating prior to your consultations. We will perform a body composition analysis each and every session. We need accurate readings.
I have read the preceeding paragraph and I fully understand the policy.*
- Yes
3. Be on time. I know NJ/NY traffic can be tough. Do your best to allow for this. Call if you will be late. We will do our best to accommodate you.
I have read the preceeding paragraph and I fully understand the policy.*
- Yes
4. Your progress depends on your adherence to your personalized program. That means compliance with the 4 components essential for your optimum health potential (see below). If you struggle with any component we will discuss and handle it. We will be successful with complete honesty and dedication to your program. Remember, we are only here to help.
I have read the preceeding paragraph and I fully understand the policy.*
- Yes
5. If you run out of prescribed supplements or nutrition shakes, don’t hesitate to call us. We can arrange for drop shipping to your home or work.
I have read the preceeding paragraph and I fully understand the policy.*
- Yes
6. Your food and exercise logbook is critical to your program. Without this information it is nearly impossible for us to educate and support you. This also gives us clarity as to how certain foods affect your metabolism. We will only consult you if your logbook is present at your consult.
I have read the preceeding paragraph and I fully understand the policy.*
- Yes
7. Aging and disease is optional. As your health and nutrition coach my quest is to educate you once and for all how to look better, feel better and live better. You can do this! I believe in you. Sign below if you believe in you.
Signature - please sign using your mouse or iPad stylus:*
Today's Date
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Attendance at one of our HEALTH and VITALITY workshops is MANDATORY. You will be notified of the schedule. We will only offer long-term support and goal setting after attending this motivational educational seminar. Bring Family and Friends!

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Form – HPQ Revisit Form

Step 1 of 2

Please complete this form in one sitting. Incomplete forms cannot be saved.

1. Keep your appointments. Your success depends on our ability to keep you motivated, handle obstacles and chart your progress! If you must re-schedule, give us plenty of notice (24 hours). It is ultimately your responsibility to stay on course with your personal program.

2. Drink plenty of water (always) and avoid sweating prior to your consultations. We will perform a body composition analysis each and every session. We need accurate readings.

3. Be on time. I know NJ/NY traffic can be tough. Do your best to allow for this. Call if you will be late. We will do our best to accommodate you.

5. If you run out of prescribed supplements or nutrition shakes, don’t hesitate to call us. We can arrange for drop shipping to your home or work.

6. Your food and exercise logbook is critical to your program. Without this information it is nearly impossible for us to educate and support you. This also gives us clarity as to how certain foods affect your metabolism. We will only consult you if your logbook is present at your consult.

7. Aging and disease is optional. As your health and nutrition coach my quest is to educate you once and for all how to look better, feel better and live better. You can do this! I believe in you. Sign below if you believe in you.

Missed Appointment Policy

• Solaris Whole Health requires a 24 hour notice to reschedule or cancel an appointment

• In the absence of notice, clients will be charged for the full amount of the office visit.

I am in agreement with the terms of the Missed Appointment Policy outlined above.

Recents Blogs

Understanding Auto-Brewery Syndrome: When Your Body Becomes a Brewery

Why Breakfast Really Is The Most Important Meal Of The Day

The Root Cause Revolution: A New Approach to Everyday Health

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