Your personal information
Firstname*
Lastname*
Birth Date (AAAA/MM/JJ)
Family doctor or clinic
Phone number
Additional phone number
Email*
Employment
Address
City
Postal Code
How many people do you live with? --- 0 1 2 3 4+
About your consultations:
Refered by*
Nutritionist* Choose … Amélie Deschamps Ariane Lavigne Brianna McFadden Maximilien Van Haaster Mélanie Mantha Mélanie Olivier
Spoken language during your consultations?
Do you have insurance for nutritionnist/dietitian? * Yes No
Where would you want to meet with us? --- Remote Spécifik Performance (2260, rue des Carrières, Montréal) Clinique Sport Santé Laurentides (26, avenue Lafleur sud, Saint-Sauveur) Mouvement Optimal (384, rue de St-Jovite, Mont-Tremblant) Centre Performe Plus (3600 Boulevard de la Grande-Allée, Boisbriand) Évolution Physio (3115, Boulevard de la Pinière, suite 110, Terrebonne) Clinique Chiroaxion (2174 boul. Marie-Victorin, Longueuil) Clinique l'Avenir (1575, Boulevard de l’Avenir, bureau 440, Laval)
If you are a minor:
Tutor name
Relationship with the tutor
Your Objectives:
What are the food habits that you would like to work on over the next three months?
What are your perfomance or wellness goals?
Au niveau individuel, quels sont les sujets que vous aimeriez approfondir: Supplements Weight management Recipes Recovery Snacks Trips Restaurants Detailed meal plans Eating and competing
We'd love to have your comments and questions and would be happy to answer them
Please validate the following statements I understand that a cancellation fee corresponding to 50% of the price of the scheduled consultation will be billed to me if I notify less than one working day before my appointment for a cancellation I am informed and I accept the prices and methods of payment. We prefer payments by interac transfermade immediately after receiving the service. By checking this box, I confirm that: I have not been diagnosed with COVID-19, I do not have any symptoms associated with COVID-19, I have not traveled in the last 14 days, I have not been in contact with a person who would have answered yes to the 3 criteria above. I give my consent to use the Zoom platform for remote consultations, if this is the case. I agree to receive information via email. Usually no more than one newsletter / month
