Congratulations. You’re Booked!

Hello !

I’m so excited that you decided to take part in my Alkalize with Andrea cleanse! I know this is going to be a life changing week for you as it was for me almost 10 years ago! Don’t stress over the little things, we are going to have a healthy good time!

Please answer the following pre-screening questions.

Everyone needs to be at a certain level of health in order for me to facilitate you though THIS cleanse and for you to reap the full benefits. THIS cleanse is very intense and effective. Don’t let that scare you in any way as many people breeze right though it!!

For example, an individual that has gone through chemotherapy within the last 3 years has a very toxic body. The cleanse will release these toxins too quickly and they may become very ill. Other health conditions can cause other complications during the cleanse ranging from mild to severe.

Just because you may answer yes to some of these questions does not mean that you cannot participate. Most people are just fine to do this cleanse. Please be absolutely truthful. Failure to reveal all your health issues could result in your not being able to complete the cleanse.

Please answer yes or no to these questions and if you feel the need to explain then feel free to do so.


Do you presently have or have you ever had any of the following:



   Diabetes Type I

   Heart Disease or Problems

   Severe Cardiac Disease


   Severe Anemias

   GI Hemorrhage Perforation

   Severe Hemorrhoids

   Severe Diverticulosis

   Ulcerative Colitis

   Crohn’s Disease

   Presently Pregnant

   Abdominal Hernia

   Recent Colon Surgery

   Renal Insufficiency

   Fissures Fistulas

   Mental Health Problems


Are You Currently Under A Doctor’s Care? (Required)

If so, please describe:


Have you ever been diagnosed with cancer? (Required)

If so, how long have you been in remission?

Did you undergo chemo or radiation?

Date of Last Chemo Treatment
(Leave blank if not applicable. Approximate if exact date is not known.)



Birth Date (Required)


Best Contact Phone # (Required)


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