Intake Form | Ayurveda

First name

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Birthday

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Primary Concern?

Any other physical or mental wellbeing concerns?

Existing Medical History -if none type none

Medications - if none type none

List your allergies? If none , type none.

When would you start the detox? Approx.

Which Detox are you opting for

Physical Package - Recipes Digital $250

Digital (Supplements Provided) - $175

Digital package (no suplements provided) - $95

Signature - I undersign that all information is correct and a transfer will be made within 24 hours (bank information provided)

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Banking details (online payments coming soon):

Butterfield Bank

BNTB BDA$

Shara F Crunden

0604080540011

I will contact you by email as soon as your product is ready for collection

Much Love