Please fill out the form to complete your Reset registration.

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address

Phone Number

Date of birth

YYYY

Occupation

Emergency Contact Name

Emergency Contact Phone Number

How did you hear about Reset?

The following information is designed to help design a Self-Tuning kit that is based on your individual needs and appropriate for your condition. It is not intended as a substitute for a complete physical examination and assessment by a physician. It is recommended that each client undergo a medical examination prior to the initiation of exercises. With this understanding, please answer the following questions accordingly.

What is your reason for requesting a Reset session?

In your own words, please share your story and describe what has led to your request. This can include information such as what your symptoms are, what relieves or aggravates them and how long have you had them.

Have you seen a medical doctor or other health care practioner for this condition?

Yes

If so, who and what was the diagnosis and recommendation?

Please describe if you have followed any of the recommendations and what the results have been.

What is your biggest concern regarding your reason for requesting a Reset session?

Has it affected your job, finances, sleep, happiness ...?

Does anyone in your family have similar issues?

Yes

If so, please elaborate.

Do you currently exercise? If so, please elaborate.

What are your expectations for your Reset session?

Please describe what you hope to gain, learn, work on...

Please list anything else we should know about you that would help create your kit.