Medicine Man Session
Natural Remedies for Today's Ailments
Signature
Name
*
First Name
Last Name
Email
*
example@example.com
CellPhone Number
*
-
Area Code
Phone Number
Mailing Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
What ailment are you dealing with?
*
fibroids
endometriosis
When were you first diagnosed with the ailment?
*
What treatments have you done to heal your body? Be specific
*
Are you pregnant or nursing?
*
Yes, I am pregnant
Yes, I am nursing
No, I am not pregnant or nursing
List all medications you are currently taking. List the reasons why you are taking them.
*
Check all the foods you currently consume
*
processed foods
meat
dairy
sweets
fruits
fried foods
vegetables
breads/grains
organic foods
Appointment
*
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Session Fee
$
99.99
One-on-one session
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Total
$
0.00
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