insurance Full Name(Required)Age(Required)DOB MM slash DD slash YYYY Current Weight(Required)Height(Required)Any food allergies? Foods to avoid? (This includes any negative reactions to gluten, dairy, sugar or alcohol)(Required)Please describe your current digestion and select the answer below that best applies to you:Frequency of Bowel Movements(Required)2 or more times daily1 time dailyless than once dailyFrequency of Constipation(Required)Every daya few times per weerarely everFrequency of Diarrhea(Required)Every daya few times per weekrarely everFrequency of Heartburn, Acid Reflux, Hiccups(Required)Every daya few times per weekrarely everFrequency of Bloating or After Meals(Required)All the timeoccasionallyrarely everFrequency of Burping or Gas After Meals(Required)All the timeoccasionallyrarely everOn a scale of 1-10, please rate your current sleep quality and how many hours nightly on average? How many times do you wake up through the night? Do you wake up energized in the morning?(Required)Please describe your lifestyle and level of stress day to day?(Required)Current Calories and Macros?(Required)How many meals do you eat per day?(Required)Current training schedule and rep schemes?(Required)What time of day do you normally train?(Required)Current OTC supplements?(Required)Current medications?(Required)Will you be going through insurance?YesNoPlease upload your insurance card hereMax. file size: 10 MB.Please provide the name and address of your pharmacy(Required)WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT 1. I understand that ryze health & wellness and its agents do not replace the need for a primary care physician. i understand that i should Always consult with my Primary physician or qualified health professional on any matters regarding my health. I understand that I am choosing to participate in the supplement recommendations provided at my own will and release ryze health & wellness and its agents of any liability for adverse reactions that may come from the supplements advised to me. 2. I am fully aware of any risks or hazards related to the treatments provided by ryze health & Wellness and its agents. I voluntarily assume full responsibility for any risks of loss, property damage, or personal injury, including death, that may be sustained by me, as a result of being engaged in such activities, WHETHER CAUSED BY THE NEGLIGENCE OF RELEASEES or otherwise, to the fullest extent allowed by law. 3. It is my express intent that this Waiver and Hold Harmless Agreement shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representative, if I am deceased, and shall be deemed as a RELEASE, WAIVER, DISCHARGE, AND COVENANT NOT TO SUE the above-named RELEASEES. I hereby further agree that this Waiver of Liability and Hold Harmless Agreement shall be construed in accordance with the laws of the State of North Carolina and that any mediation, suit, or other proceeding must be filed or entered into only in North Carolina and the federal or state courts of North Carolina. 4. I understand that all sales packages and/or payments for service are final and NON-REFUNDABLE. 5. I am aware that all information exchanged is property of Ryze HRT and is not to be shared or copied. SignatureCAPTCHA
