Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Have you received FSM treatment?
*
Yes
No
When did you first receive FSM treatment?
*
-
Year
-
Month
Day
Date
Name of FSM practitioner(s) who treated you
*
Have you read "The Resonance Effect"?
*
Yes
No
Brief description of your FSM treatment experience
What conditions were you treated for with FSM?
Neck pain
Back pain
Fibromyalgia
Joint pain
Nerve pain
Post-surgical pain
Sports injuries
TMJ pain
Headaches/Migraines
Concussion
Brain fog
Neuropathy
Post-Viral Symptoms
Long COVID
Shingles pain
Arthritis
Tendinitis
Sprains/Strains
Torn ligaments
Muscle injuries
Disc problems
Sciatica
Chronic inflammation
Autoimmune conditions
CRPS/RSD
Post-surgical inflammation
Anxiety
Depression
Sleep issues
Scar tissue
Wound healing
Kidney stones
Abdominal pain
Digestive issues
Other
How has FSM impacted your life?
*
Community & Professional Background (optional)
What medical practitioners do you have connections with in your area? Are you involved in any local healthcare or wellness organizations? Do you have experience with public speaking or community outreach? Are you active on social media? If yes, which platforms? What geographic area would you like to serve as an ambassador?
Motivation & Goals (optional)
Why do you want to become an FSM Ambassador? What unique qualities would you bring to the role? How do you envision promoting FSM in your community? What goals would you like to achieve as an FSM Ambassador?
Availability
*
How many hours per month can you commit to ambassador activities? Are you available to attend monthly Zoom meetings? Are you willing to travel locally for outreach activities?
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