I am looking to cancel:
*
Other (please specify)
First Name
*
Last Name
*
Email
*
Requested date of Cancellation
*
All cancellations are applied on the 14th day from this submission. However, if you’d prefer a date after this please select from the below.
Reason for Cancellation
*
Other (please specify)
On a scale of 1 to 10, how likely would you recommend 5th Element Wellness to someone else?
*
Bad
Good
What would it take to keep you as a member? (no promises, we just don’t want to die without knowing the truth)
*
Would you like to continue working with your Coach through our App?
*
Yes
No
Other comments
Submit