Client Interest Form

PIPPINS WELLNESS CENTER

Your Wellness Journey Starts Here

Thank you for your interest in the Pippins Wellness Center. This brief form helps our team understand your interests, goals, and preferences before your FREE consultation so we can provide a more personalized experience.

First name

Last name

Phone

Email

Preferred Method of Contact:

Phone Call

Text Message

Email

Best Time to Contact You:

Morning

Afternoon

Evening

Anytime

What brings you to the Wellness Center?

What is your PRIMARY wellness goal?

When would you like to get started?

Would you like to learn about available financing/payment options that may include promotional 0% APR plans for qualified applicants?

Yes — Please Tell Me More

Maybe — I'd Like More Information

No, Thank You

How did you hear about us?

Anything you would like us to know?

Signature

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CONSENT & ACKNOWLEDGMENT

I authorize Pippins Wellness Center to contact me regarding my inquiry, consultation, requested services, and scheduling using the contact information and preferred communication method I provided. I understand that standard message/data rates may apply to text messages and that I may opt out of promotional texts.

I confirm that the information I have provided is accurate to the best of my knowledge.

I understand that this is a preliminary inquiry form and does not establish a provider-patient relationship, constitute medical advice, diagnosis, or treatment, or determine whether I am eligible for a particular service.

I understand that some wellness services may not be appropriate for everyone. Additional health history, screening, informed consent, and/or medical clearance may be required before receiving certain services.