Request Your Seat(s)
*NOTE: If you have attended ANY of our previous seminars, you are no longer eligible. For further information, you may call our office and/or schedule your consultation if you have not already done so.
Best Phone # To Contact You:
Best Time To Call You:
Is the phone number you chose above a mobile (cell) phone? If so, who is your service provider?
Ex: Verizon, AT&T, T-Mobile, Sprint, etc.
How Many Seats Are You Requesting:
[limited to 2 seats per reservation]
Name & Relationship to You of Your Guest:
ex. John Smith, Spouse
On What Date Would You Like to Attend?
Please refer to the calendar for seminar dates
What are Your Main Health Concerns or Symptoms?
ex. Diabetes, Thryroid, Numbness, Trouble Sleeping, etc.
What Medications are You Taking Right Now?
How Did You Hear About Us?
Have You Attended Dr. J's Seminar Before?
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