Donation Form

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Sponsor's Full Name *

First Name Last Name
Sponsor's E-mail *

Confirmation Email
Sponsor's Phone Number *

Area Code Phone Number
Sponsor's Address *

Street Address

Street Address Line 2

City State

Zip Code Country
Type of Support Donation or Gift

$ 249 Wellness Consultation (Normally $295 included a 2nd free visit) – Support 1 person consultation fee; 3rd and subsequent visits are $45 each $ 450 Cancer Support(Normally $500 per six months) – Support 1 person consultation fee for a six month period (Includes unlimited visits).
TOTAL RECIPIENT DONATION OR GIFT
Comments
Recipient's Full Name *

First Name Last Name
Recipient's E-mail
example@example.com
Recipient's Phone Number

Area Code Phone Number
Recipient's Address

Street Address

Street Address Line 2

City State

Zip Code Country

Total Sponsorship or Gift Amount:

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Change a Friend or Love One's Life. Sponsor/Gift Their Consultation Today!