Full Name*

Email Address*


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How did you hear about us/our program?* (Check ALL that Apply)

- If so, who?
- If so, which event?
- If so, which media source?

How do you feel about incorporating prayer & scripture into your healing program? *

What best describes your spirituality? *

Which best describes your issue?* (Check ALL that Apply)

If you have Fibroids, how many and what sizes are they according to your most recent test and what date did that take place? *

As much as possible, please provide exact details on the number, size and location if known.

Medical overview of your story/case *

What is your current physical condition? *

Not Symptomatic

What are your most severe symptoms? *

What is your current emotional condition? * (Check ALL that Apply)


What is your current spiritual condition? * (Check ALL that Apply)

Do you exercise regularly and if so how often and what kind of exercise? *

What best describes your diet? *

What time zone are you in? *

What best describes your budget for this treatment? *

Do you have any other medical issues that we should be aware of? * (Check ALL that Apply)

What, if any, medications are you currently taking and what do they treat? *

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