Women's Health: Hormones and Weight Gain Registration Form
Conscious Conversation with Women's Health Senior Specialist, Rega Stellar Pe, with the World Institute for Incurable Diseases
Sunday July 20th 5:30 - 7 PM PDT
(Sunday July 21, 8:30 - 10 AM PHT)
Customer Details:
Full Name
*
First Name
Last Name
Phone Number
*
E-mail
*
example@example.com
City and Country
*
How did you hear about us?
*
Please Select
Instagram
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Referral
Other
Who referred you?
*
What phase are you at:
*
Regular Cycle
Perimenopause
Menopause
Post Menopause
Other
What are your main concerns/issues/frustrations?
Questions for Rega:
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Women's Health: Hormones and Weight Gain Registration Fee
$
15.00
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