Member Intake Form

Please fill out the form as completely as possible. The more we know about you, the better we can assist you.
(We will never share any of your information with anyone without your express permission.)

 

Member Intake Form
(lbs.)
(ounces daily)
(ounces daily)
(Ex. O negative, A+)
(Ex: Surgery, asthma, heart disease, depression, etc.)
(Ex: Prescriptions, legal & illegal recreational drugs, vitamins, herbs, etc.)
(Hours daily)
(Ex: Weight training, aerobics, pilates, yoga, Bemer, reiki, etc.)

Note: We at Good Shepherd Ministries, Herbal Health Review, and all subsidiaries comply with all privacy, confidentiality, and client information laws. Your information is used by us only and is collected to understand and assist you. We will never share your information with anyone else without your express permission. See our privacy policy.