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 Claudia Côté-Robitaille 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 Plateau Mont-Royal (4450 St-Denis, 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 I will be charged 50% of the consultation if I change or cancel an appointment less than a business day before my appointment. I am aware and I accept the prices and payment methods. We accept payment by interac transfer, credit cards, checks or cash. I accept to receive information by email from Vivaï. (Usually, no more than one newsletter per month.)
