Minerals & Metals Package


Mailing Address(Required)
MM slash DD slash YYYY
If Female, please indicate if you are:

Medication / Supplements


Dietary Information

Which of the following foods do you consume regularly?(Required)
What type of cookware do you use (check all that apply)?(Required)
Do you tend to skip meals?(Required)
Check any of the following special dietary program you current follow or have followed in the past. Check all that apply.(Required)


On average, how often do you have a bowel movement?(Required)
Do you regularly take laxatives?(Required)

Kidneys & Liver Function

Kidneys & Liver Function(Required)
Liver Function. Check all that apply.(Required)


What time do you usually go to sleep?(Required)
What time do you usually wake up?(Required)
Do you sleep in a completely dark room (very little to no light)?(Required)
Is there a television, computer, or electrical appliance within 6 feet of your bed?(Required)
Do you turn off your phone/computer/television at least 1 hour before going to bed?(Required)


How often do you exercise?(Required)
What types of exercise do you regularly engage in?(Required)
If you engage in resistance training, what is your average recovery timeframe?

Personal Care/Household Products

Please list the brand name you use most next to each product.

Dental Information

Do you have amalgams (silver fillings)?(Required)
Do you have any root canal treated teeth?(Required)
Have you ever had any wisdom teeth extracted?(Required)
Have you had any other dental surgery (gum, jaw surgery etc.)(Required)

General Health Function

Rate each condition using the following scale: 5 = severe, 4 = strong, 3 = moderate, 2 = mild, 1 = weak, 0 = not present)
Have you been diagnosed with any autoimmune disease(s)?
Were you ever diagnosed with cancer?
Have you ever been diagnosed with Cardiovascular Disease?

Females Only

The following 3 questions are only for females

Terms of Service


It is common practice for naturopaths, nutritionists and other non-licensed practitioners to collect your signature on a form such as this. By doing so you acknowledge and accept that Deeper Health Consulting Inc:

  • is not medically licensed;

  • is not a substitute for advice from a doctor;

  • recommends that you consult your doctor before making any changes to your diet or exercise regime or taking any dietary supplement;

  • does not warrant the accuracy of any information provided;

  • is not liable for any losses you may suffer by relying on our advice;

  • does not guaranty results of recommended products;

  • is not a covered entity or a business associate of a covered entity under HIPAA.

    By your signature below, and/or by instructing us to provide advice and services to you, you indicate your agreement to these terms.

    What we do and do not do

    We obtain a set of laboratory test results [from various certified laboratories in the United States] and provide you with a nutritional interpretation of those test results that you can use exclusively as an educational tool for personal health purposes.

    Your doctor may use the same test results to diagnose and treat disease, but we do not do this. The information we provide is not intended to, cannot, and should not be expected to be a substitute for a personal consultation with your own medically licensed doctor. We do not accept any liability for any failure to identify any medical condition or disease; this is not the purpose of our services.

    We may provide you with information relating to products that we believe might benefit you, but such information is not to be taken as an endorsement or recommendation. Some such products may not be available without a prescription, but we do not dispense or prescribe any prescription products. The information provided is intended for educational purposes only and should not be taken as professional medical advice or used as a substitute for medical care. We are not responsible for any adverse affects or consequences that may result, either directly or indirectly, from that information.

    Consult your doctor

    We are not qualified medical advisors and make no claims to be so. The information we provide should not be taken to be, and is not a substitute for, personal medical advice and instruction. You should not take any action based solely on our advice.

    You should consult your doctor:

  • for any medical interpretation of your test results; on

  • any matter relating to your health and well-being;

  • before making any changes to your exercise or diet;

  • before taking any nutritional, herbal, homeopathic or hormonal supplementation;

  • before beginning any therapy.

    Exclusion of warranties

    We will provide our services to you with reasonable care and skill. But we make no other warranty, express or implied, with respect to those services. All other warranties are excluded to the maximum extent permitted by law.

    We make no warranty as to the accuracy of the laboratory test results we receive. We make no warranty, expressed or implied, as to the quality or effectiveness of any diagnosis, apparatus, treatment or product. In no event will we be liable for any physical or mental injury, or any negative side effects, that may arise from the use of any such diagnosis, apparatus, treatment or product.

    We believe that the information we provide, including that on our web sites, brochures, flyers and information packets, is accurate, but we cannot guarantee such accuracy. We therefore make no warranty as to the accuracy of that information, and it should not be relied upon as being correct, complete or accurate. It is your responsibility to verify such matters independently from primary sources of information and by taking specific professional advice.

    Exclusion of liability

    If you rely on, buy or use a product or therapy, you do so at your own risk. Each person is different, and the way someone reacts to a product or therapy may be significantly different from another. We cannot predict how you may react to any particular product or therapy.

    To the maximum extent permitted by law, we exclude:

  • any and all liability in contract, tort (including negligence), breach of statutory duty, or otherwise for any direct, indirect, special, incidental, or consequential costs, losses, claims, damages, expenses, or proceedings (including but not limited to loss of profits and wasted management time) incurred or suffered by you arising directly or indirectly out of or in connection with our services, including but not limited to any loss, damage or expense arising from any defect, error, imperfection, fault, mistake or inaccuracy with the information or advice we provide;

  • any and all liability for injury or loss arising out of the use of, or reliance on, the laboratory results and/or the dietary, supplement and lifestyle suggestions we may provide;

  • any and all liability for injury or loss arising from any product or treatment you may choose to take;

  • any and all liability for any failure to identify any medical condition or disease. You understand and agree that this is not the purpose of our services.

    This is a comprehensive limitation of liability that applies to all damages of any kind, including (without limitation) compensatory, direct, indirect or consequential damages, loss of data, income or profit, loss of or damage to property and claims of third parties.

    No recommendation

    All material and information we may provide about products and therapies is provided solely for educational purposes and for use when discussing your health with your doctor. By providing you with such material and information, we do not necessarily endorse, recommend or promote any such product or therapy.

    Refund Policy

    Payment for services must be paid upon receipt of this agreement unless a special promotion offers payments in installment(s). No refunds will be issued by Deeper Health Consulting, Inc., even upon decision of a client not to continue with the full terms/length of the contract.


    I have read and understood the above and I agree to it.
  • Name
    MM slash DD slash YYYY

    By typing my name above, I acknowledge that this acts as a legal, electronic signature.


    Balance minerals. Detoxify metals.

    $749 (price includes lab test fees)


    Comprehensive intake form/medical history screening to access medical history & lifestyle

    3 Sessions (includes two 45 minute sessions and one 90 minute Results & Recommendations session)

    Email support

    Customized DRESS protocol (Diet, Rest, Exercise, Stress Reduction, Supplementation)

    Paleo Lifestyle customizable guide

    Educational information

    Lab Test included with package: Hair Tissue Mineral Analysis

    11 nutrient minerals & 10 toxic metals analyzed to assess mineral imbalances and toxicity levels that directly and indirectly affect adrenal and thyroid function, metabolic rate, energy levels, sugar and carbohydrate tolerance, and immune system function.


    √ FREE Hair Tissue Mineral Analysis re-test (between 8-12 weeks after original test) and 30 minute post package consult including retest results analysis & updated protocol

    √ FREE 15 ml bottle of doTerra Zendocrine Essential Oil Detoxification Blend ($32 Retail Value)