Dish for Dosha juice cleanse intake form
Welcome to Dish for Dosha! This is the intake form that allows you to participate in Chef Cecilia's signature, local seasonal raw juice cleanse programs. Programs are either 3, 6 or 9 days long. Each 3 day juice set is $129 and it include as a variety of 18 8oz. raw juices plus one Lemon Orchid water
Email address *
Chef Cecilia's signature seasonal raw juice cleanse: 3 day cleanse includes a variety of 18 juices and an orchid tonic water (soups are seasonal, and only available on a very limited basis)
Hi! I am Chef Cecilia Arosemena, your personal raw and seasonal juice chef. I am here to help start your detox process, where you will explore the healthy eating/ healthy living juicing life! so lets get started wiht some basics : What is your name, phone number and email address? *
Your answer
Have you ever done a juice cleanse before? *
skip if no, or If so, how did it work for you? how long? what kind of cleanse did you try? *
Your answer
What are your intentions while doing a juice cleanse? what kind of goals would you like to achieve regarding your health and nutrition? *
Your answer
Our juices are formulated as synergistic juice blends sourced locally, and focusing on seasonal ingredients in our region. besides that, do you have any other systems or functions of the body would you like us to focus on? *
Are there any fruits or veggies you strongly dislike, and would like us to NOT use it in your juices? *
Your answer
Do you have any food allergies? *
Your answer
Are you on any medication? if so, do you know if you shouldn't consume particular foods with them? if you are on medication, we strongly recommend to consult your doctor before starting a program like this to make sure that this is something safe for a more severe condition. Some medications may fight with some foods, such as grapefruit, so please ask your doctor if unsure. We are not doctors or nurses, so please be diligent on your research regarding your medications and juicing, for our chefs cannot be held responsible if you are to have a reaction with your prescribed medications. *
Your answer
What is a regular day look like for you these days? How do you sleep? What are your energy levels like? What are your stress levels like? *
Your answer
Is there anything else you feel like sharing? *
Your answer
How did you hear about us? *
Who is this caring and sharing of yours that led you here? We'd like to thank them :)
Your answer
May 2017 cleanse pick up dates are : Tuesday July 11 at 5 pm, Friday July 14 early afternoon, and monday July 17 at the YWCA at 530 pm pm. You would begin your cleanse the following morning. Which of those days would you like to pick up the first 3 days of your cleanse? you can start the cleanse on any of the dates mentioned above. whats your chosen start date? please note that the 3rd day on a juice cleanse is usually a day that your body will ask you for more rest and liquids. be mindful of this when you schedule your dates. *
Your answer
Thank you for taking the time to tell us a little about you
From here, we will compile your information, and get back to you If you;d like to discuss more issues, concerns, requests, please feel free to email us at, or call/text us at 520 309 9055. Now lets get our juicing on!
A copy of your responses will be emailed to the address you provided.
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