Nutrition Application Form

1
Date
Date
Month
Day
Year
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Name
First Name
Last Name
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How did you hear about Amy?
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E-mail
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Number
Area Code
Phone Number
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Can you share what your reasons are for wanting 1-1 support from Amy?What are your goals? What are your current health/wellness struggles?
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Please list any ailments, medical issues and medications.
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Have you done any nutrition programmes before? If so, please list.
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Do you feel you need to support your weight / body composition?
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Please confirm that you understand that Amy O Mara is not a doctor / medically trained. All information she shares is for informational purposes and is not intended to replace medical treatment.
I confirm I understand.
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I advice all my clients check with their doctor before making any dietary/lifestyle changes. Please confirm you understand that it is your responsibility to check with your own GP before making any dietary changes & you will not hold Amy O Mara accountable in the unlikely event you become unwell/have an adverse reaction while on her programme.
I confirm I will take responsibility to check with my healthcare provider should i feel neccesary and will not hold Amy O Mara accountable for any adverse reactions that may occur.
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