Custom Patch Protocol Request Form
Please complete the survey below to receive a customized patching protocol tailored just for you. The more details you provide, the better we can tailor recommendations to support you health journey. After submitting the form, please give us 2-3 business days to get your recommendations back. You will receive a text when your protocol is ready and in your email. We are so excited for you to begin to experience the amazing repair and regenerative powers of phototherapy like millions of other individuals have already experienced.
First Name
*
Last Name
*
Email Address (to send your results to you)
*
Cellphone number (will notify when your results are ready)
*
Age
*
Who referred you? Please share their name so we can thank them and let them know to follow up with you!
Do you have any family history of heart disease, diabetes, or cancer? If so, please share which condition and your relation to the family member affected.
*
Please check any of the following that you are experiencing. You may select multiple if needed.
Chronic Fatigue
Chronic Pain
Musculoskeletal Pain
Fibromyalgia
Frequent Headaches / Migraines
Depression
Sleeping Problems
Insomnia
Memory Fog
Clarity / Focus
Racing Mind
Anxiety
ADD / ADHD
Mold Illness
Lyme Disease
PCOS
Infertility
Menopause
Hormonal Imbalance
Asthma
Blood Sugar Issues
Food Cravings
Allergies
Heart Condition
Hashimoto's
Thyroid Disease
Auto-Immune Disorder
Heartburn / Digestive Issues
Constipation
Diarrhea
Vision Issues
Balancing Issues
High Blood Pressure
Neuropathy
Cold Hands/Feet
Varicose Veins
Accelerated Signs of Aging
Please tell me in your own words what your main goal is for starting your healing journey. If you have multiple goals, please list them in order of priority. (Less pain, less inflammation, less joint stiffness, less brain fog, better mental focus, more energy, increased strength, better balance, better sleep, less anxiety/depression, improve athletic performance, etc)
*
On a scale of 1 to 10, how much is this affecting your life right now? (1 = not much, 10= a lot)
If you woke up in a few weeks to 30 days and this problem was less and you felt better and more alive than you have in years.... Would that make your life better and easier than it is today right now?
How committed are you to helping yourself feel better and heal better? If it only cost $3 to $6 a day (depending on your health) to feel better and younger and truly enjoy life again, would it be worth it?
Please Select
Yes absolutely! I want to feel better and feel younger! Send me info!
No, I'll just stay the same and deal with it.
NOTE:
After submitting the form, please give us 2-3 business days to get your recommendations back. You will receive a text when your protocol is ready and in your email. We are so excited for you to begin to experience the amazing repair and regenerative powers of phototherapy like millions of other individuals have already experienced.
DISCLAIMER:
The recommendations provided through this suggested patch protocol form are not intended to be interpreted as medical advice, diagnosis, treatment, or cure for any symptoms or health conditions. These suggestions are made based on the individual qualities of each patch that LifeWave provides to help enhance your overall well-being. By submitting this form for patching recommendations, you acknowledge that this does not assume formal care or that we are responsible for your health. These recommendations are intended for informational purposes only and do not establish a doctor-patient relationship. Always consult with your health provider before making any decisions regarding your health.
Submit
Should be Empty: