Premium Membership

First and Last Name *

Address *

City *

State *

ZIP *

Email Address *

Phone Number *

Height *

Age *

Weight (lbs) *

Current and past health conditions and symptoms *

Current diet and lifestyle *

Current medications

Food allergies

On a scale of 1-10 with 1 being the lowest and 10 being the highest, what is your level of motivation and determination to heal yourself? *

<strong>Initial Consultation - 90 Minute initial consultation plus iris analysis</strong>: $150

Subscription Item - $60.00 Monthly Recurring Membership *

30 days free then $60/month