Body Sass® Cleanse Intake Form

First Name

Last Name

Email Address

Phone Number

Do you have any major health issues? (obesity, high blood pressure, ulcerative colitis, etc.) *

Do you take any medications, prescription or over-the-counter? *

What are your goals during this Cleanse? What do you hope to achieve? *

Do you have Celiac Disease? * Do you have Celiac Disease? * Yes No

Are you currently receiving chemotherapy or radiation treatments? * Are you currently receiving chemotherapy or radiation treatments? * Yes No

Do you have Diabetes? * Do you have Diabetes? * Yes, Type 1 Yes, Type 2 No