Remote Testing Application

NEW CLIENTS

Thank you for your interest in the Remote Testing Program with the owner, founder, and Critical Care Clinician, Cynthia Hofmann-Coale. Below is an application that we need you to fill out in order to be approved for our Remote Testing program.

Please take time to carefully review the program and consider the requirements and financial commitments and whether it is feasible for you and your family.

Once we have received the application back from you, we will be personally reviewing it with Cynthia and will determine whether or not you are approved for the Remote Testing Program at the Well of Life Center.

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PROGRAM COMMMITMENT

At the Well of Life Center, we are committed to doing everything in our power to restore health to your body as a whole. In turn, we require that all Remote Testing clients commit wholeheartedly to the program that we offer, and to the nutritional protocol that your Clinician designs specifically for you. Please take the time to review the requirements shown below and consider whether they are feasible for you and your family.

Remote Testing Initial Consultation Appointments are $635. This fee is required at the time of scheduling your appointment and is non-refundable. *

I understand and am committed to pay this initial consultation fee
I am unable to meet these financial guidelines

Once you have scheduled your appointment, the following is a list of the information we need from you in order to assess your body optimally. It is important that this information is as up-to-date as possible, so we ask that you provide us with this information within 24 hours of your scheduled remote testing appointment. Please check each item below if you agree to follow through on this commitment.

Two photos of yourself. (One with the front of your body and one photo of the back of your body)
Express Mail ship the 5 saliva swabs to our office
Express Mail ship medications/supplements

We will also need you to complete a Nutritional Assessment Questionnaire, which may be completed online. *

I understand and am committed to this
I am unable to meet this commitment

You may expect to receive your Clinician’s recommendations and a new protocol via email within 24 hours of your remote testing session. We ask that you call our front desk within 24 hours of receiving this email to order your nutrition. Your order will then be mailed to you so that you can begin your new regimen upon receiving your nutrition. *

I understand the follow appointment cost and the importance of ordering nutrition within this time period
I am unable to meet these financial guidelines

All follow-up appointments are $375 and are expected to be paid at the time of scheduling *

I understand the payment fee schedule
I am unable to meet these financial guidelines

At each follow up appointment, we ask that you provide us with the following information 24 hours before your scheduled remote testing appointment. Please check each item below if you agree to follow through on this commitment

Two photos of yourself. (One with the front of your body and one photo of the back of your body)
Express Mail ship the 5 saliva swabs to our office
Express Mail ship medications/supplements
A detailed description of your health and current symptoms you may be experiencing
A 3-day food log with additional detailed information regarding bowel movements, quality of sleep, ounces of water, etc.

If you marked "unable" for any of the commitments above and you do NOT want to pursue this program, but would like more information about in-office options we have available, please contact our Client Advocate Team at clientadvocate@welloflifecenter.com.

PERSONAL PROFILE

Today's Date: *

Name: *

Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Email: *

Main Phone Number: *

Age: *

How did you hear about us? *

Referred by friend or family member
Online search
Social Media
Other (list below)

Other:

If you were referred by someone, please give us their full name so that we can thank them with a personal gift! (1 name only, please)

HEALTH HISTORY

What symptoms are you experiencing? *

How long ago did these symptoms begin? *

Have you received any diagnosis at this time? *

If so, what is it?

What treatment plan(s), if any, has been prescribed for you by your medical doctor?

Are you currently taking any medications? *

If yes, what are they?

What other holistic modality have you participated in, and when?

Are you currently under a holistic practitioner's care? *

Please list any dental work you have had done: Include amalgams, root canals, crowns, caps, etc. *

When was your most recent dental work performed? *

How frequently do you see a dentist? *

Is your dentist a biological dentist? *

Yes
No
I'm not sure

Have you had an mercury fillings? *

If so, how many and when were they put in?

Should we find that your mercury fillings are negatively impacting your current state of health, would you be willing to have them removed? *

Yes
No
Maybe

DIETARY INTAKE: DAY 1

Your diet may be one of the keys to better health. We require a minimum of 3 days of food intake. You do not need to wait 3 days to fill it out; you can simply give us a detailed example of what your typical dietary intake is during this course of time. Be sure to include approximate amounts of meat, dairy, vegetables, fruits, breads, cereals, grains, fats (butter, margarine, oil, etc.), candies, sweets, junk food, and liquids, including water.

Date: *

BREAKFAST:

Time: *

What did you eat for breakfast? *

LUNCH:

Time: *

What did you eat for lunch? *

DINNER:

Time: *

What did you eat for dinner? *

SNACKS:

Did you have any snacks throughout the day? If so, what were they and approximately what times did you have them? *

WATER INTAKE:

How much ounces of water did you drink this day? *

HOURS OF SLEEP:

How many hours of sleep did you have this day? *

QUALITY OF SLEEP:

Please rate your quality of sleep (1=Poor, 5=Good) *

BOWEL MOVEMENTS:

How many bowel movements did you have this day and what was their consistency? *

DIETARY INTAKE: DAY 2

Date: *

BREAKFAST:

Time: *

What did you eat for breakfast? *

LUNCH:

Time: *

What did you eat for lunch? *

DINNER:

Time: *

What did you eat for dinner? *

SNACKS:

Did you have any snacks throughout the day? If so, what were they and approximately what times did you eat them? *

WATER INTAKE:

How much ounces of water did you drink this day? *

HOURS OF SLEEP:

How many hours of sleep did you have this day? *

QUALITY OF SLEEP:

Please rate your quality of sleep (1=Poor, 5=Good) *

BOWEL MOVEMENTS:

How many bowel movements did you have this day and what was their consistency? *

DIETARY INTAKE: DAY 3

Date *

BREAKFAST:

Time *

What did you eat for breakfast? *

LUNCH:

Time: *

What did you eat for lunch? *

DINNER:

Time: *

What did you eat for dinner? *

DINNER:

Did you have any snacks throughout the day? If so, what were they and approximately what times did you have them? *

WATER INTAKE:

How much ounces of water did you drink this day? *

HOURS OF SLEEP:

How many hours of sleep did you have this day? *

QUALITY OF SLEEP:

Please rate your quality of sleep (1=Poor, 5=Good) (copy) *

BOWEL MOVEMENTS:

How many bowel movements did you have this day and what was their consistency? *

CLIENT CONSENT

TYPE YOUR NAME AND SIGN BELOW TO ATTEST TO THE FOLLOWING: I have read, acknowledged, and agree to the Agreement and Release of Liability:

Please click HERE to read our Agreement and Release of Liability. Then, sign by typing your full name in the box above. By signing, you are acknowledging that you have read and accept the terms and conditions of the Agreement and Release of Liability.

Client Signature: *

Clear Signature

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NEW CLIENTS