nourishment survey

Please check all that you are willing to participate in for acceptance into our culture. *

participation in group calls sharing wins and challenges in private Facebook setting committing to giving this a REAL try, for 90 days Drinking half your weight in ounces of CLEAN water every day

Are you willing to show up EVERY Wednesday evening for our Mastermind Call at 7:30EST? If not, please explain. *

We have options: 2 plans.
Plan 1.
Reset90 Original.
You track EVERYTHING YOU EAT, in MyFitnessPal app, and share a Google Sheet with Dr. Jodi weekly so she can recalibrate / track progress.

Plan 2.
Reset90 Plan B.
No tracking. We co-create your plan, boundaries around food, etc. A bit more free formed, but tailored more for the NON TECHNO ladies.

I used to hate filling this part out, and now I LOVE to. You will get there. We will get you there.

Do you have any health issues? Are you on medication? If so please list name, what it is for, and how long you have been on it. *

List the name and brand of each supplement you are currently taking, and what you take it for. *

What is your biggest obstacle right now to achieving your physical goals? *

When was your last physical and what was the outcome? *

Why here, now, with us? *

Client Consent to Be Treated
I authorize Dr. Jodi Dinnerman to provide ongoing consulting and support for my health goals. I understand that no guarantees can or will be made as to results of care, treatment, or supplements / diet prescribed and intend this consent to be continuing in nature even after a diagnosis has been made and treatment recommended. This consent will remain in full force until revoked in writing.
Financial Agreement
I acknowledge that I am financially responsible for all services provided and that the program involves a reoccurring payment monthly in the amount advertised. I understand that this amount will be charged to my account monthly until I ask that it is stopped. I acknowledge that all of my questions have been answered about Dr. Dinnerman's services, and that they are not a guarantee of results.
Privacy
I acknowledge that Dr. Dinnerman will not share my information or disclose my involvement with her program outside of the normal and customary procedures of the program (joining facebook community, etc).
Refunds
I acknowledge that my initial investment of $195 for the intake process to Reset90 is non refundable, but can be transferred per the terms described. I acknowldege that my monthly investment, once made, is not refundable but can be used as credit for other services that Dr. Dinnerman offers.

By typing my name below I am consenting to these terms.

Nourishment Survey