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.
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Name:
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Your answer
Email:
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Your answer
Best Phone # To Contact You:
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Your answer
Best Time To Call You:
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Morning
Afternoon
Early Evening
No Preference
Is the phone number you chose above a mobile (cell) phone? If so, who is your service provider?
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Ex: Verizon, AT&T, T-Mobile, Sprint, etc.
Your answer
How Many Seats Are You Requesting:
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[limited to 2 seats per reservation]
1
2
Name & Relationship to You of Your Guest:
ex. John Smith, Spouse
Your answer
On What Date Would You Like to Attend?
*
Please refer to the calendar for seminar dates
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YYYY
What are Your Main Health Concerns or Symptoms?
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ex. Diabetes, Thryroid, Numbness, Trouble Sleeping, etc.
Your answer
What Medications are You Taking Right Now?
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How Did You Hear About Us?
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Your answer
Have You Attended Dr. J's Seminar Before?
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Yes
No
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