CLEANSE INTAKE FORM Livi ng. JUICE Select a Living Juice Cleanse . Personal Information ©. Juice Cleanse (8 Drinks, Variety of 4 Juices) Last Name: CD iuice Fast (5 Green Vitality Juices & 3 Fresh Start Juices) First Name: Street Address: City: Number of Days ae i Email O 1ay © 3pay Phone oe a Cai (EEN ELS CO Detoxification [General Well Being Sta EI) CT Increased Energy © Weight Loss OC Increased Mental Clarity CD Other: * All orders must be placed by 2:00 pm A 9 for guaranteed next day start date How did yu WELL TE OFriend OC Editorial 5 A CD Advertisement Online aA OF otter © Pick Up at Yellow Monkey Village Pe Minar ee ' cash check Civico _ *aié: Ship (Charges vary based on location) CoAmex © Mastercard Yes CONo 5 A Card Number: Prior Cleanse Experience OC No OD Yes: | have read and understand the Living Juice Cleanse Protocol and meet all requirements to begin a Living Juice Cleanse/Fast. | am 18 years of age or older and confirm my details below, Signature: Date: ~ Yellow Monkey Vllage| 792 Route 35, Cross River, NY 10518 914.763.6320 wu. drnklivingjuce.com | wwfacebook.com/drinklivingjuce | wuinstagram.com/drinklivingjuice