NAME *

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Last Name

ADDRESS *

Address 1

Address 2

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PREFERRED DATE *

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YYYY

HAVE YOU USED OUR SERVICES BEFORE? *

First Time Client

Returning Client

INDIVIDUAL BR+ NAD THERAPY SERVICES

250mg NAD+

500mg NAD+

3-DAY NAD+

NADyouth

BR+ NAD THERAPY DETOX PROGRAMS

ALCOHOL DETOX: 6-Day Program

ALCOHOL DETOX: VIVITROL®

ANTIDEPRESSANT DETOX: 6-Day Program

BENZO, METHADONE + SUBOXONE DETOX: 15-Day Program

OPIATE DETOX: 10-Day Program

OPIATE DETOX: VIVITROL®

SMOKING/NICOTINE DETOX: 6-Day Program

CHRONIC DISEASE PROGRAMS

ALZHEIMER'S DISEASE: 6-Day Program

LYME & AUTOIMMUNE DISEASE: 6-Day Program

PARKINSON'S DISEASE: 6-Day Program

SPECIAL BR+ NAD THERAPY SERVICES

ANTI-AGING DETOX: 3-Day Program

INSOMNIA DETOX: 3-Day Program

WEIGHT LOSS DETOX

TERMS OF SERVICE *

GENERAL BOOKING: ‣ Payments will be charged at the time of scheduling or at the time of service. ‣ $100 fee will be charged if the nurse arrives to your appointment and does not render the service. CANCELLATIONS: ‣ WE REQUIRE AT LEAST 24-HOURS ADVANCE NOTICE OF CANCELLATION. Holistic Home Detox understands that situations may arise that require you to cancel or postpone your appointment, however we kindly request 24-hours notice be provided if you need to cancel or reschedule your appointment. ‣ If you book your service less than 24-hours in advance, there is a $100 cancellation fee. REFUNDS: ‣ In the event that a package or series of treatments has begun, these services will be considered to have been rendered even though the full series may not have been completed. Should you wish to discontinue your treatment in the midst of a series, you will not be credited of unused treatments and/or credited a treatment.

*I agree to the Terms of Service