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Prospective Client Application

Please complete and submit. I use this to screen potential new clients. Nothing you enter will be the “wrong answer”, I am checking that what you’re dealing with will fit with my treatment program.

Gender
Are you currently a patient of mine

Here’s a list of symptoms, check any if you’re experiencing:

Thank you very much for your time filling this out! I will be back with you promptly, usually within 24 to 48 hours to let you know if you’re a candidate for my program.

 Thanks -Dr. J

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