General Registration

Free Consultation Registration Form

Complete this form before your free consultation. We will contact you to set an appointment when we receive your submission. All information is confidential and only seen by Dr. Smith.

Chronic Pain • Weight Loss • Stop Smoking • Excessive Drinking • Drug Abuse • Break Ups
Phobias • Gambling • Depression • Stress • Memory Improvement

1Basic Information
2Contact Details
3Referral Information
4Questionnaire
5For Excessive Drinking Only
  • We appreciate the confidence you place in us to resolve your lifestyle issues without medication.

    Complete this registration form before your initial consultation. The information you provide will be utilized to develop a personal plan and to optimize a positive outcome. This content and our interactions are strictly confidential.

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  • Select date MM slash DD slash YYYY

WEIGHT LOSS

PAIN & MIGRAINE

STOP SMOKING

ANXIETY & DEPRESSION

ALCOHOL & DRUGS

GAMBLING