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Fill out Health Questionnaire for Free Consultation

Tell us a little about yourself and we will send you Free - a Nutritional Bar, Nutritional Sampler, Audio, and Information Pack - tailored especially for you.

All fields marked with an asterisk* must be filled out.


First Name: *
Last Name: *
Address: *
 
City: *
State: *
Postal Code: *
Country:
E-Mail: *
Day Phone: *

Do you shop in Health Stores?
Yes      
No      

Do you buy organic produce?
Yes      
No      

Do you take any supplements?
Yes      
No      

What are they?

Do you take any prescribed or over the counter medications?
Yes      
No      

What are they for?

Do you exercise?
Yes      
No      

If yes, what?

Have you heard of any of these green foods? (Check all that apply)
wheat grass      
spirulina      
chlorella      
barley green      
wild blue green algae      

Have you heard about the new research on how wild blue green algae helps to fight cancer and virus cells?
Yes      
No      

Are you interested in better...? (Check all that apply.)
Energy      
Endurance      
Mental Clarity      
Resistance to Illness      
Digestion      
Weight Control      
Other (Explain)      


What would be your health goals right now?

Would you like to work out of your home sharing natural and organic food supplements with free training we provide?
Yes      
No      

Give us a good time to reach you?
   

Thank you for filling out our health questionnaire.
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Wild and Organic Food
Ann & James Thompson
53 Eastlake Road
Mt. Pleasant, SC 29464
1-843-216-2176
Customer Service: aquaverde1@aol.com

Copyright 2003 Disclaimer: These products are not intended to diagnose, treat, cure, or prevent any disease Last Updated on 8/01/2015