CWC Modality Request Form
Your Name
*
First Name
Last Name
Email
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example@example.com
Modality Request
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Please Select
Infrared Sauna
Red Light Therapy
Hyberbaric Oxygen Therapy (HBOT)
Counseling & Mental Health Services
IV Vitamin Therapy
Halotherapy
Traditional Sauna
Homeopathic care
Health Coaching
Other
Are you submitting this request as a client, practitioner, applicant, or someone else?
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Please Select
Active CWC Client or Caregiver
CWC-Affiliated Practitioner
Interested CWC-affiliated practitioner
Health Professional
Other
Request Summary: (Provide a concise summary of the request and why it's being made)
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Desired Outcome or Suggested Solutions:
*
Supporting Documents (if applicable)
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Research and other scientific articles that support this modality for cancer patients
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Date of Submission
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