Become a Client Request Form

Thank you for your interest in purchasing whole food supplements from Diverse Health Services.

In order to approve your account, we need a little more information. If you would please fill out the following form, we can get the approval process started.

If you are interested in setting up an appointment with one of the doctors in our office to further discuss your health concerns, we would be happy to assist you with that. Dr. Tent D.C., Dr. Gill D.C., and Dr. Senechal D.C. are accepting new patients at this time. Also, both doctors offer appointments via Skype or Facetime if you are not local to our office. Please call us to schedule if you are interested.

* Indicates required questions

Name *

First

Last

Address *

City *

Country *

State *

US/CA: or:

Zip/Postal Code *

Phone # *

Email *

Referred By *

Birthdate *

/ /

Sex *

Height *

Weight *

Major Health Complaint *

Medications currently taking *

Supplements/Vitamins currently taking *

Are you a healthcare provider? *

Yes
No

Is there a Healthcare Provider who offers these products in your area? *

Yes
No
I don't know