Breathe 1oz

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20-2930-3940-4950-5960-6970+

Relief from what top 3 symptoms (required)

How much sweaty activity weekly? (required)

How many ounces of water do you drink daily? (required)

How many eliminations per day? (required)

How much daily energy (1 = lowest energy level; 10 = highest energy level) do you have? (required)

12345678910

What surgeries have you had and when? (required)

What kind of prescription medication do you take? Circle NONE if applicable. (required)

I understand the services performed here are at all times restricted to consultation on nutritional matters intended for the maintenance of the best possible state of natural health and do not involve the diagnosing, treatment, or prescribing of remedies for disease.