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A Clinic that helps to heal naturally.

Offering a positive approach to health, wellbeing and balance.

Questionnaire

What is your name?*

What is your email address?*

How did you find us?

GoogleOther search engineYellow pagesFriendother

What therapy are you interested in?

BioresonanceHypnotherapyHolistic TherapiesEFTCombination of all ticked

What would you like us to help you with?

SmokingHealth & WellbeingAllergiesPain/IllnessWeight LossAnxiety/Stress/Panic AttacksConfidence/Self EsteemOther

If other, please give brief details

What age group are you?

18 - 2526 - 3536 - 4546 - 55over 55

If you want to become a non smoker, How long have you smoked?

under 5 years5 - 10 years10 - 20 yearsover 20 years

How many cigarettes do you smoke per day?

10 - 1515 - 2020 - 3030 - 4040 +

Would you like us to send you further details?*

YesNoI will contact you to make an appointment

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Thank you for contacting us. We will get back to you as soon as possible