Treatment Application Form

Please enable JavaScript in your browser to complete this form.
Do you drink Alcohol
Do you smoke
Do you have hypertension or hypotension
Do you have a history of seizures
Do you have diabetes
If yes, are you insulin dependent
Hepatitis A, B or C
Slow Heart Rate:
Heart Disease
Multiple Choice
Respiratory Problems
High Blood Pressure
Renal Disease
Nerve Damage
Stroke
Bleeding
Liver Problems
History of Seizures
Heart Problems
Low Blood Pressure
Asthma
Fainting
AIDS / HIV Positive
Hepatitis A, B, or C
When you are ready and you have finished filling in all the required fields, select the SUBMIT button. Check that you do not receive an error message to ensure that the information has been sent properly.

Call us: (800) 889-4171

Join us! It will only take a minute