FOOT DETOX CONSULTATION FORM

Foot Detox Consultation Form

Kindly Complete the Foot Detox Consultation Form

Full Name*

Email Address*

Phone Number*

Date*

Complete Address*

Do you experience fatigue or low energy levels especially around 3 pm in the afternoon?*

Do you experience brain fog, lack of concentration and or poor memory?*

Do you eat fatty foods,fast foods, and pre -prepared foods, or fried foods on a regular basis?*

Do you drink sodas and coffee during the day to get yourself going?*

Do you smoke cigarette?*

Do crave or eat sugary snacks, candies, or desserts?*

Do you have less than 2 bowels movement per day?*

Do you feel sleepy after meals,bloated, and or gassy?*

Do you experience heartburn or indigestion after eating?*

Are you over weight or do you rarely exercise?*

Do you experience reoccuring yeast or fungal infections?*

Do you experience frequent headaches or migraines?*

Do you have arthritis aches, and pain stiffness?*

Do you take prescriptive medicines on a regular basis?*

Do you live with or near polluted air,water, or other environmental pollution?*

Do you use fluoridated toothpaste or drink flouridated/chlorinated water?*

Do you experience depression or mood swings, ( mental highs or lows?*

Do you have bad breathe or excessive body odor?*

Do you have food allergies or bad skin?*

Are you showing signs of premature aging?*

Have you ever used an internal cleansing product or followed a complete internal cleansing program?*

If Yes

If any of these conditions exists then FOOT DETOX is not for you*

Sign Here:

Toll Free: (833) 953-1380
Mon-Sat: 10:00am-7:00pm, Sunday: Closed

Address: 905 Flat Shoals Rd SE, Conyers, Ga 30094