Please complete and submit this form to arrange your half-price ($97) one-hour consultation. All fields are required. Name Email Date of birth MarriedWidowedSingleDivorcedIn a relationship Address Telephone Skype ID Occupation Your timezone Please give details of your availability for the purpose of booking your consultation The two key questions/concerns that you'd like to address in your consultation: 1. 2. Medical history (operations/any medical condition): Do you smoke? YesNo Weight Height Any specific dietary regimen—vegetarian, vegan or other (if none, write 'none'): Exercise (what kind, how often) (if none, write 'none'): Please list any medical drugs and/or supplements that you may be taking (if none, write 'none'): If you are undergoing medical or psychiatric treatment, please specify here (if none, write 'none'): In completing and submitting this form, you acknowledge that the information provided during a coaching session with Olga Sheean is for educational purposes only and is not intended to be a substitute for medical advice, diagnosis or treatment, where required.