Clinical Assessment Booking

Pure Wellness Referral Program

Your Pure Wellness practitioner has recommended a Clinical Assessment at Healthy Living. Complete the short form below and an HL Assessment Specialist will contact you to confirm your appointment.

Please have your Pure Wellness assessment prescription available while completing this form.

Patient Name

Email Address

Phone Number

Your Pure Wellness Practitioner

Assessment Prescribed

Styku Body Composition & Anthropometric Assessment Cardiovascular Fitness & Recovery Assessment Strength & Muscle-Capacity Profile Functional Movement Screen Trainer Consultation & Tailored Fitness Plan Progress Reassessment Functional Capacity Assessment

Preferred Day & Time — Option 1

Preferred Day & Time — Option 2

Preferred Day & Time — Option 3

Additional Information (Optional)