Client Profile

1. Full Name*

2. Email Address*

3. Mobile*

4. WhatsApp Number*

5. Country*

6. Age*

7. How did you hear about us/our program?* (Check ALL that Apply)

- If so, who?
- If so, which event?
- If so, which media source?

8. How do you feel about incorporating prayer & scripture into your healing program? *

9. What best describes your spirituality? *

10. Which best describes your issue?* (Check ALL that Apply and Specify diagnosis/any pertinent details below)

Describe your issue in detail:

11. If you have Fibroids, how many and what sizes are they according to your most recent test and what date did that take place? *

As much as possible, please provide exact details on the number, size and location if known.

12. If you have Gut Issues, which of the following do you experience? * (Check ALL that Apply and detail how you experience it)

Describe your gut issues in detail:

13. Medical overview of your story/case *

14. What are your most severe symptoms? *

15. What is your current emotional condition? * (Check ALL that Apply)


16. What is your current spiritual condition? * (Check ALL that Apply)

17. Do you exercise regularly and if so how often and what kind of exercise? *

18. What is your occupation? Do you have a sedentary or very active lifestyle? Does your work require much physical activity? *

19. What kind of support system do you have at home to encourage and help you on this journey? Strong, Moderate, Weak or Non-Existent? Please describe. *

20. What best describes your diet? *

21. What Allergies do you have, if any? Please list ALL and severity of response. *

22. Do you have any other medical issues that we should be aware of? * (Check ALL that Apply)

23. What, if any, medications have you taken in the past (including any form of Birth Control) and how long were you on it? *

24. What, if any, medications are you currently taking and what do they treat? *

25. What best describes your budget for this treatment? *

26. What time zone are you in? *


Join Waitlist We’re so excited about your response to our products! Thank you for your patience as we pause to build up our inventory to get them to you faster! Please provide your valid email below to be notified as soon as we’re back in stock!


Discount will appear in your cart