Well of Life Center for Holistic Healthcare

Metabolic Balance Paperwork

New Client Appointment Checklist

5

Complete and submit form below

5
Please arrive at least 15 minutes early for your first appointment.

These guidelines are in place for your protection and ours, as we strive to serve you to the best of our ability.

Please understand the importance of keeping your appointments. We do have a 48 hour new client/24 hour regular client appointment cancellation policy that is strictly enforced.

New Client Form

PERSONAL PROFILE

Please click HERE to download a guide on how to measure your circumferences correctly.

Declaration of Consent and Privacy Practice

The aforementioned data is sent to Metabolic Balance GmbH & Co. KG to allow said company to create a nutrition plan as part of the participation of the Metabolic Balance® Program. After the creation of the nutrition plan, Metabolic Balance GmbH & Co. KG will transmit the plan to your personal coach. Thereby your personal coach has access to the above data and nutrition plan to provide comprehensive advice under the Metabolic Balance® nutrition concept to you. Your coach and Metabolic Balance® will use your data solely for the above purposes and will not pass it on to third parties. We need your personal details and health data to be able to fulfill our contractual obligation to create a personalized nutrition plan and provide comprehensive coaching sessions to you. Under Art. 15 of the General Data Protection Regulation (GDPR), you are entitled to ask the contractual parties at any time for full details of the personal data collected about your health and person. In addition, under Art. 17 of the GDPR you are entitled at any time to demand the correction, deletion or suspension of individual items of personal data. Moreover, you are entitled, at any time and without stating a reason, to exercise your right of refusal and to modify your given consent for future purposes, or revoke it entirely. You can send your revocation either by mail or email to your contractual partner (your personal coach, see above). In cases of data privacy violations, the data subject is entitled to lodge a complaint with the competent supervisory authority. The competent supervisory authority for data privacy issues is the data privacy representative of the German Federal State in which our company has its registered headquarters.

Information on food consumption / Eating habits as well as food allergies

Food Preferences:

Please fast 12 hours before blood drawing - only pure water is allowed, do not eat or drink anything else!

Initial Questionnaire

Please take a moment to review these important details regarding this program. Once you have read and understood each point, please check the box to initial that you agree to do these requirements.
Please review the following information about your lab work and check the box to initial that you have read and understand. Your folder contains additional instructions from Ulta Labs for your review.
Please click HERE to read our Metabolic Balance Consents and Disclaimers and our Agreement and Release of Liability form. Then, sign below. By signing, you are acknowledging that you have read and accept the terms and conditions.

Pin It on Pinterest