Client Registration Card

Date:

First Name(s): Last Name:

Address:

City: State: Zip:

Home #: Cell #:

Email address: Please email more info

I attended today for:

Complimentary Event Information Gathering Have an issue/pain I may like to address

Are you retired?

Do you have, or have had in the past year, cancer?

Do you have diabetes?

Do you have any autoimmune conditions?

You:

Yes No

Yes No

Yes No

Yes No

Spouse:

Yes No

Yes No

Yes No

Yes No

Would you be interested in our financing if you choose to move forward with therapy?

Yes No

Yes No

If I were to choose this option, the #1 thing I would address is , and

the second priority to address would be

How do you want your life to be different after receiving regenerative therapy?

From what you learned today about regenerative therapy, what are you most excited about?

Pain Relief Joint Regeneration Avoiding Surgery

Please select the BEST appointment time(s) TOMORROW for you & your spouse (if married)

8:00 9:00 10:00 11:00 12:00 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00

Special Instructions: