|
Purchaser |
|
|
|
|
|
Name |
|
|
|
Mr. Mrs. Ms |
|
Address |
|
|
City |
|
|
State |
|
|
Zip Code |
|
|
Country |
|
|
Phone |
|
|
Fax |
|
|
E-Mail |
|
|
|
|
|
Sexual Enhancement
Questions |
(Please complete this form to make individualized
tapes series) |
|
Sexual Preference, Same sex, Heterosexual,
Bisexual |
|
|
Name you like to be called |
|
|
If you have a partner and you would like
the partners name in tape, write name here |
|
|
Age/marital status |
|
|
DO YOU HAVE ANY MEDICAL PROBLEMS |
|
|
Explain Problem in detail
|
|
|
Write down any traumatic experiences you
recently had |
|
|
Form of payment. Check, Money Order, Credit
Card
|
|
|
Comments Please include here if you wish
the Aromatherapy program with the hypnosis
series. |
|
|
|