PEMF and Bioresonance

Do you have any type of battery operated medical device such as a pacemaker or insulin pump? (Unfortunately, if answered 'Yes' then we can not use bioelectric therapy. Please feel free to contact us about other available modalities.)

Yes

No

First name

Last name

Phone

Email

Address

Birthday

Month

Day

Year

Briefly describe any symptoms you are experiencing:

How long have you been experiencing these symptoms?

Are you currently seeing a medical professional for any symptoms?

Yes

No

What time of day works best for you to receive a follow up call?

You will be contacted by our Peer Support Specialist within 48hrs of submitting this form. Thank you very much for reaching out.