Initial Medical Questionnaire

We require an introduction call prior to joining one of our programs.
We do not sell but want to serve you best!
Please fill out the information with best times and days to reach you.

Let us know if Texting is best to reach you initially.

Help us know how we can serve you better

Name

Email Address

Phone

Birthday

Street Address

City

Postal / Zip code

Region/State/Province

Please share how you heard about us? Are you desiring to schedule a consultation or become a member of the Detox Shoppe? Members are those with prior consultations, get access to our private Facebook Group Please be specific on how we can help you. One Consultation or Product Purchase gives you Detox Shoppe membership and Access to our FB group. Email us on how to get started. Thank you.

Please list any new diagnosis or new symptoms that have occured in the last 6 months. PLEASE FILL OUT THE TEMPLATE HEALTH QUESTIONNAIRE BELOW TO BEGIN SCHEDULING PROCESS WITH US. THIS FORM CANNOT BE DONE ON A MOBILE DEVICE. MOBILE DEVICES MUST BE PRINTED AND SCANNED TO contact@detoxshoppe.com COMPUTERS CAN SAVE AND EMAIL FORM TO US. We apologize for the inconvenience.

I declare that the info I’ve provided is accurate & complete

Email *We do not sell your email to anyone. It is for purpose of reaching you and sharing upcoming events. Please let us know if you are not receiving our emails

I agree to the terms & conditions

Detox-Shoppe

Initial Medical Questionnaire We require an introduction call prior to joining one of our programs. We do not sell but want to serve you best! Please fill out the information with best times and days to reach you. Let us know if Texting is best to reach you initially.

Initial Medical Questionnaire

We require an introduction call prior to joining one of our programs.
We do not sell but want to serve you best!
Please fill out the information with best times and days to reach you.

Let us know if Texting is best to reach you initially.