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Please fill out this form so I can get to know you better.

Tell us about any other symptoms (please check all that apply)

Have you been diagnosed with any medical issues?

Do you find it easy to wake up?

How is your energy throughout the day?

Tell me about your eating habits

What types of foods to you typically crave?

Digestion and Elimination

Cognitive Function

Thank you for taking the time to fill out our intake form and congratulations on taking the first step toward achiving better health and wellness. It is common practice for naturopaths, nutritionists, and other non-medical practitioners to collect your signature on a liability waiver form such as this. By signing below you acknowledge that: Joe Rignola is a Health and Nutrition Counselor, not a Medical Doctor. You are receiving nutritional counseling and any advise given should not be construed as medical advice. it is your responsibility to consult with your medical doctor before changing your diet. Joe Rignola does not treat or diagnose any disease or illness. The information provided by Wellness Punks and on Joe Rignola’s web sites, brochures, flyers, and information packets are believed to be extremely accurate, but such accuracy cannot be guaranteed by Joe Rignola, his independent representatives, associates and affiliates as we are not the originators of the underlying data used in the interpretation. The undersigned releases Wellness Punks and Joe Rignola from any liability for injury or loss arising out of the use of, or reliance on, the laboratory results and/or the dietary, supplement and lifestyle suggestions provided. Before making any changes to the exercise, diet or nutritional or hormonal supplementation of the undersigned, a physician should be consulted. Further, the undersigned releases Wellness Punks, Joe Rignola, his lab partners, independent representatives, associates or affiliates from any and all liability for any failure to identify any medical condition or disease. It is understood and agreed that this is not the purpose of their services. Electronic Signature. By submitting this form with your name below, you are agreeing to the above disclaimer. Thank you.

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