Reduced price treatment application
Full Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Current age
Gender
Male
Female
Other
Which treatments are you interested in having?
*
Acupuncture/massage only
Chinese herbs only
Acupuncture/massage and Chinese herbs
I'd like to discuss this at the initial consultation before deciding
What is your current employment status?
*
Employed full-time
Employed part-time
Unemployed
Unemployed and on benefits
Please add any information you'd like me to consider regarding your ability to pay the standard price for treatment
What do you feel is the maximum price you can afford per week for your treatments (including herbs if you want to have them)?
*
Submit
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