Page 1 of 2
Group Guided Parasite Cleanse Registration and Payment
First Name
*
Last Name
*
Email Address
*
Phone Number
*
Age
*
City, State
*
How did you hear about this program?
*
A
Referred by a friend
B
Flyer
C
Instagram
D
Facebook
E
Quiz result email
F
Other
Health Background
Have you ever tried a cleanse or detox protocol before?
*
A
No, never
B
Yes, once
C
Yes, multiple times
Are you currently taking any medications?
*
A
No
B
Yes
Do you have any medical diagnoses I should know about?
*
This helps me coach you safely and effectively. Nothing here disqualifies you — I just need the full picture.
What are you most looking forward to on the other side of this?
*
Better energy
Better sleep
Better digestion
Mood stability
Clear skin
Other
How would you like to receive your herbs?
*
A
Local Pick Up (Craftsbury, VT)
B
Via Mail (free shipping)
Commitment
I understand this is an 8-week group program with a 60-day herbal protocol. I'm committing to show up for the calls and follow the protocol as guided.
*
I agree
I understand this program is educational and coaching-based, not medical treatment. I'll consult my doctor before starting if I have any health concerns, and I'm responsible for informing my doctor of any medications or conditions relevant to this cleanse.
*
I agree
Signature
*
Sign here
Date
*
Submit