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Please call me (see 'About Me' page) or complete form below.

The minimum requested information is -

     Name, phone, and email...

     The additional information would be most helpful, however,

     and will expedite my service to you.


Client Data Sheet

First and Last Name:*

City and State:

Phone Number:*


Date of Birth --- Sex:

Tobacco Smoker YES / NO

Meds currently taken (and dosages), for what condition, and what year diagnosed.:

Height / weight:

FOR DISABILITY ONLY: Occupation / duties; NET monthly income (self-employed); GROSS monthly income (if employee)

Any comments you wish to add:*

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