Name
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First Name
Last Name
Email Address
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Phone
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(###)
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Age
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Gender
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Male
Female
Height
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Hair Color
Blonde
Brown
Black
Grey
Red
Marital Status
Single
Life Partner
Married
Divorced/Separated
How many kids do you have?
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0
1
2
3
4
5
6+
Occupation
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How did you find out about us?
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What are your main health concerns or conditions?
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Please list supplement, dose, and condition, if any, that it treats for each supplement you take currently.
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Please list medication, why you take it, and how long you have been taking it for each medicine you currently take.
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Please list any surgeries you have had and the dates.
Please list illnesses in your family such as heart disease, diabetes, cancer, arthritis, TB, etc.
Breakfast
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List foods and beverages.
Other Beverages
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Please describe the type and amount of fish you consume.
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Are you or have you ever been a vegetarian or vegan?
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Never been either vegetarian or vegan
Currently vegetarian
Past vegetarian
Currently vega
Past vegan
Please describe the type and amount of water you drink daily.
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Do you have a water softener?
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Yes
No
How frequently do you eat at restaurants?
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What time do you typically go to bed?
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What time do you typically wake up?
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Do you have any sleep concerns?
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Please check the types of alcohol you drink
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How often do you drink?
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How many drinks do you have when you choose to drink?
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How often and what types of tobacco do you use?
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What are your hobbies?
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Symptoms
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Symptoms
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Symptoms
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Symptoms
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Symptoms
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Symptoms
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Symptoms
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Symptoms
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Symptoms
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Symptoms
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Symptoms
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Symptoms
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Symptoms
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Symptoms
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Symptoms for Women Only
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Symptoms for Men Only
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I understand that Kelly Storrs has received her certification in Nutritional Balancing Science from Westbrook University, an accredited school in West Virginia. I understand that Kelly Storrs is a non-licensed, non-medical health practitioner/consultant. Kelly Storrs consulted, studied and worked with Dr. Larry Wilson and his advanced students in the field of Nutritional Balancing from 2016 to 2020 and has been active in nutrition-based healing since 2011.
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I request that Kelly Storrs of R Cubed, LLC, a Virginia Limited Liability Company, design a nutritional balancing program for me based on a Hair Tissue Mineral Analysis (HTMA) from Analytical Research Labs, Inc. for the purpose of balancing my body’s systems, reducing stress and enhancing energy.
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I understand that Nutritional Balancing is not intended as diagnosis, prescription, treatment or cure for any disease or health condition, mental or physical, real or imaginary. Nutritional Balancing and the information provided by R Cubed, LLC is also not intended as a substitute for regular medical care and professional medical treatment. I am encouraged to seek a second opinion from a medical care provider. I understand that under no circumstances should any medication be discontinued without first consulting the prescribing medical provider. I understand that any application of recommendations provided by R Cubed, LLC and Kelly Storrs is at my discretion and sole risk.
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I understand that if I follow the Nutritional Balancing Program, I am strongly encouraged to purchase a HTMA retest in 4-5 months to determine if the suggested program needs to be modified. Therefore, in order for me to continue to solicit assistance from R Cubed, LLC, I agree to have a re-test performed within the suggested timeframe but am under no obligation to purchase a retest if I no longer desire the assistance of R Cubed, LLC.
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I understand and agree to the following terms: All fees are due at the time of service request (before test kit is mailed). Fees are payable by credit card or check, no exceptions. Services are not invoiced. Insurance is not accepted at this time. Refunds will be processed only within the first 30 days following purchase, provided a hair test has not been ordered; no refunds will be provided after 30 days. Further, a 15% processing fee will be charged for all credit card returns if you pay by credit card and then opt not to have the service performed within 30 days of payment.
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Date for Signature
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MM
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YYYY
Signature
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By typing your name here, you are digitally signing this form and indicating that you understand the following:
Nutritional Balancing is a means to reduce stress and balance body chemistry. It is not intended as diagnosis, treatment or prescription for any condition or disease. Kelly Storrs holds a certificate in Nutritional Balancing Science and works as an unlicensed Nutritional Counselor.
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