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Purchaser |
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Name |
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Mr. Mrs. Ms |
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Address |
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City |
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State |
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Zip Code |
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Country |
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Phone |
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Fax |
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E-Mail |
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Chronic pain
Questions |
(Please complete this form to make individualized
tapes series) |
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Name you like to be called |
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Age/marital status |
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Please explain your problem and medical condition
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Past treatments used and outcome |
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Write down activities or time of day when
pain is worse |
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Write down any traumatic experiences you
recently had |
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Diagnosis by doctor |
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Form of payment. Check, Money Order, Credit
Card
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Comments Please include here if you wish
the Aromatherapy program with the hypnosis
series. |
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