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.
Name: *
Email: *
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? *
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy