Full Name*

Email Address*

Mobile*

WhatsApp Number*

Country*

Age*

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

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

Desire it because of my faith Not opposed to it Uncomfortable

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 *

Please include dates to provide a timeline where possible--also identifying any surgeries and/or advanced reproductive technology treatments (such as IUI or IVF) you have undergone.

What is your current physical condition? *

Very Symptomatic
Moderately Symptomatic
Not Symptomatic

What are your most severe symptoms? *

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

Fearful
Sad
Indifferent/Numb
Content
Happy

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

Hopeless
Indifferent
Hopeful

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

What best describes your diet? *

Traditional diet including red meat
Traditional diet primarily poultry and fish
Pescatarian: primarily fish
Vegetarian
Vegan
 Fibroid Elimination Diet

What time zone are you in? *

Eastern Central Mountain Pacific

What best describes your budget for this treatment? *

$350 to $500 $500 to $750 $750 to $1,000 $1,500 to $2,500 $2,500 to $3,500 $3,500 to $5,000

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? *