Telephone consultation

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0 height="100%"><tr> <td valign="top" width=200 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <A HREF="id23.htm" TARGET="_top" TITLE="Back to Wellness Center"><U>Back to Wellness Center</U></A></div> <div> <A HREF="id54.htm" TARGET="_top" TITLE="Homeopathy"><U>Homeopathy</U></A></div> <div> <A HREF="id62.htm" TARGET="_top" TITLE="The Truth about Homeopathy"><U>The Truth about Homeopathy</U></A></div> <div> <B>Telephone consultation</B></div> <div> <A HREF="id59.htm" TARGET="_top" TITLE="EFT Treatment Homeopathy"><U>EFT Treatment  & Homeopathy</U></A></div> <div> <A HREF="id55.htm" TARGET="_top" TITLE="Soothing Bedtime Story"><U>Soothing Bedtime Story</U></A></div> <div> <A HREF="id64.htm" TARGET="_top" TITLE="Bach Flower remedies"><U>Bach Flower remedies</U></A></div> <div> <A HREF="id17.htm" TARGET="_top" TITLE="Picture show"><U>Picture show</U></A></div> <div> <IMG SRC="1e376930.jpg" border=0 width="118" height="147" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> </td> <td valign="top" BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <FONT SIZE="5" COLOR="#000000" FACE="Arial" ><B>The Beauty Group</B></FONT>     |     <A HREF="index.htm" TARGET="_top" TITLE="The Beauty Group"><U>home</U></A></div> <div> <A HREF="id23.htm" TARGET="_top" TITLE="Back to Wellness Center"><U>back to the</U></A><A HREF="id23.htm" TARGET="_top" TITLE="Back to Wellness Center"><U><B> wellness Center</B></U></A></div> <div> Telephone consultation</div> <div> If you cannot come to our office I will be able to treat you by Telephone  just print out the below Form and Fax or send to me I will send you an </div> <div> detailed questionaire that you fill out and after I have had a telephone consultation with you and evaluated your questionaire I will be able to treat you with a remedy that is appropiate to your ailment.</div> <bR> <bR> <DIV ALIGN="LEFT"></DIV> <div> <B>Homeopathic Wellness4Me Center</B></div> <div> <B>231 Pittston Ave</B></div> <div> <B>Scranton,Pa 18504</B></div> <div> <B>570 504 5848</B></div> <div>  Fax: 570 296 5613</div> <bR> <bR> <div> <B><U>NEW CLIENT REGISTRATION</U></B></div> <bR> <bR> <div> Name:_________________________ Age:_________ Birthdate: ________ Sex: ____</div> <div> Address:________________________ City:______________ State:_____ Zip:_______</div> <div> Phone: (home) _______________ (work) ______________ Email: _________________</div> <div> Occupation: ______________________</div> <div> Marital status: ____________________</div> <div> How did you hear about this office:_________________________</div> <div> Name of family doctor or clinic:____________________________</div> <div> If the patient is a child, please indicate the following:</div> <div> Mother’s Name:___________________ Child lives with you?_______</div> <div> Father’s Name:____________________ Child lives with you?_______</div> <div> What vaccinations has the child taken?______________________</div> <div> YOUR HEALTHHISTORY:</div> <div> What medications do you currently take?_______________________________________</div> <div> What medications have you taken in the past?___________________________________</div> <div>  Have you had any of the previous illnesses? (Please indicate the diagnosis and when it occurred)</div> <div> Autoimmune disease</div> <div> Cancer</div> <div> Heart Disease</div> <div> High blood pressure</div> <div> Diabetes</div> <div> Mental illness</div> <div> Neurological disorders</div> <div> Pneumonia</div> <div> Tuberculosis</div> <div> Venereal diseases</div> <div> Please write any other conditions you suffer from.</div> <div> Any surgeries or hospitalizations: Please detail with dates(Year)</div> <bR> </td> </tr></table></body>