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Our Home Natural Health Retreat Inquiry Form

Providing the following information will allow a better understanding of your condition, and enable us to help you more. Explain fully where necessary.

First Name
Last Name
Street Address
Apartment, suite, unit etc.
Country
City
State / Province / Region (if applicable)
Postal Code / Zip Code
Home Phone
Cell Phone
E-mail Address
Birth Date
Birthplace
Nationality
Marital Status
           
Sex

MEDICAL HISTORY

Please state PRIMARY HEALTH ISSUE e.g Arthritis, Asthma, Allergies, Cancer, Colitis, Constipation, Crohn's Disease, Depression, Diabetes, Digestive Disorders, Gas Intestinal Disorders, HIV, High Blood Pressure, Lupus, Mental Health (Depression, Anxiety, Stress, PTSD, Grief, Addiction, Abandonment Issues, etc), Obesity, Smoking, Weight Management, Women's Health Issues, or Other health related issue. Also state how many months/years you have been dealing with this issue.
Please state SECONDARY HEALTH ISSUE if any. Also state how many months/years you have been dealing with this issue.
What is your desired SESSION date? Please provide us with a first, second, and third date choices.














What is your payment ability? Cash/Cashier's Check/Credit Card
How did you learn about M.E.E.T Ministry and Our Home Natural Health Retreat?


Thank you for your inquiry and upon submission, one of our health center therapists will contact you as soon as possible. We look forward to serving you.

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