Natoorales Intake Form - Natoorales | Biological Sovereignty

and very –

Full Name:

First

Last

In order to process your request we need a selfie Photo of your face. Photo must be taken at daylight, good resolution. No make up. We need to get the reflection of your skin, not the chemicals on your skin. Send the photo via email to wellness@natoorales.com or via WhatsApp +52 958 115 2683

Email Address:

WhatsApp / Phone #:

Send us a FACE ONLY selfie NO MAKEUP

Date of birth:

Blood Group:

If you know your blood group

Reason for Visit:

Rate your current state of well-being on a scale 1 -10 (1 – very bad, 10 – excellent):

Medical History – Current and past, missing organs, etc:

Current Medications and/or Supplements taking:

Diagnosed Medical Conditions and Allergies:

Describe your wellness goals and in what timeframe would you like to achieve them:

Describe the food do you normally eat, your sleep and exercise:

What is your level of stress daily on a scale 1 – 10 (1 – no stress, 10 – maximum stress):

Describe the holistic services and treatments you have already utilized and the results:

Signature: Enter your name as signature:

Natoorales Intake Form