Pain Application |

Full Name:*
Middle
Email:*
Date of Birth:*
DD
MM
YYYY
Gender:*
- Male
- Female
phone number:*
Physical Address:
Street Address State / Province / Region Country
Medical Diagnose:
Patient Complaint, Pain Source and physical location in your body:*
Medical History with years you had other illnesses and at what age were you completely health:*
Patient hours of sleeping (local time, e.g 11PM-6AM):*
Attach a clear Picture
I am the patient:
- Yes
- No
Will the Patient be aware of treatment?
- Yes
- No
Payment via PayPal - You can use Credit Card as well:*
- $150 - 4 Healing Sessions Pain Relief w Money back Guaranteed
I Agree to the terms and conditions*
- I agree
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