Wellness Program Registration Form
First & Last Name
Prefered method of contact.
How did you hear about our programs?
From the Roots Holistic
A friend referred me
My health practitioner referred me
Name of your referring friend/health practitioner?
Which Wellness Program are you registering for?
Detox with a Holistic Nutritionist, One on One
Zen Wellness, Winter Session
Detox with a Holistic Nutritionist, March 18th, 2018 (registration deadline March 15th, 2018)
What is your Facebook ID/Name?
We need this to connect with you to add you to our secret Facebook group.
Which detox level are you registering form
Beginner's (14 days)
Intermediate (14 days)
Advanced (21 days, plus required supplements & botanical remedies)
The Advance program requires supplements & botanicals remedies. You have the option to purchase the required supplements on your own, however please be advised that the supplements have to be the specific brand name listed and are needed for the detox. If you would like to order through me please choose which supplements & botanicals you would like, this will be added to your base fee of $100.00. All prices include taxes. LIMITED QUANTITIES IN STOCK FIRST COME FIRST SERVE.
2 bottles of Liver Health Tincture, Orange Naturals $34.82 (average retail price for 2 bottles is $43.98- $47.98 in Health Food stores)
Bulklax® , St-Francis Herb Farm $17.29 (average retail price is approx. $22.95 in Health Food stores)
Fibre Flow (Capsules), CanPrev, $25.38 (recommended for those who can't handle or use the Bulklax)
Oréganum Plus® 1:3, St-Francis Herb Farm $11.62 (average retail price is approx. $16.79 in health food stores)
Oréganum Plus® Gel Caps, St-Francis Herb Farm $16.46 (recommended for those who can't tolerate the taste of oregano oil, average retail price is approx. $22.99 in Health Food stores)
Probiotics, CanPrev, $21.75 (average retail price is approx. $25.99-$29.99 in Health Food stores)
Emergency contact person
Emergency contact's phone number
Your Date of Birth
Weight pounds (lbs)
Height in inches
Do you have access to a scale first thing upon waking?
Physical Activity Level (please carefully read description below)
Active job (4 hrs or less) + working out less than the Low Active Leve + household chores
Sedentary job + working out less than the Low Active + household chores
Active job (8 hrs) + working out gently (yoga) 3-4 days a week + household chores
Sedentary job + working out 5 days or more a week for a minimum of 60 minutes (resistance & cardio) + household chores
Active job (8 hrs) + working out working 5 days a week for a minimum of 60 minutes (resistance & cardio) + household chores
List of medications, (including birth control, Intra-Uterine Device, vitamins & supplements including protein powders, herbal remedies):
List all health conditions you may have including allergies or sensitivities. Although not a health condition please make note if you are pre-menopausal, menopausal.
What are your personal wellness goals?
Learn what healthy eating is
Learn about healthy lifestyle practices
Maintain weight and health
Gain weight in a healthy maner
Lose weight in a healthy effective manner 1-2 lbs/week
Terms and conditions, by checking each item you are agreeing to each statement
Information provided during the program does not take into account all individual conditions and may therefore not be advisable or beneficial to all participants.
Dana Clark/From the Roots Holistic/Zen Fitness is not liable for misuse, misunderstanding, injury or health issues that may ensue from the information provided during the program.
The participant’s personal & medical information will be kept confidential unless an order by law dictates the relinquishment of such personal files.
Information provided by Dana are in accordance with recognised academic training achieved by Dana Clark and is not to be considered the treatment or suggested treatment of a Medical Doctor.
Participants must cooperate and follow through on the program in order to make it possible to reach their realistic goals.
Photo/video/Recording Release: I give permission for the use, publication and other display, including advertisements, of photos, video, and other recordings take of me while I am attending any Wellness Program. I understand that I will not be compensated in any way if any photo, video or other recording is used, published or displayed by From the Roots Holistic or Zen Fitness. I understand that my before and after pictures are excluded from this permission and that those pictures were done for my benefit only, should I wish to share them I will contact program organizers and give them permission.
In order to secure one's spot full payment or a payment plan with initial payment must be completed. If choosing to do a payment plan, you will need to have a credit card on file. If you should drop out of the program at any time all payments must be honored and the full amount paid.
Refund policy, we do not offer refunds.
Method of payment?
E-transfer (details will follow after submission)
Credit Card Payment (please fill out credit card information)
Payment plan for Zen Wellness, $100.00 down followed by 3 installments of $83.34 (invoiced via email)
Already paid via Zen Fitness
Advanced Detox participant, (you will be invoiced via email, and cay pay via e-transfer or credit card)
Do you require a formal invoice for health benefits?
No Thank you
Credit Card Payment
Detox with a Holistic Nutritionist, Beginners and Intermediate
Credit Card Number
Should be Empty: