Virtual Gastric Band Hypnosis

    Note: All your information will be held Strictly Confidential

    Full Name

    Address:

    City:

    Zip:

    Telephone (Home):

    Telephone (Cell):

    Your Email (required)

    Are you taking any medication? If so, which medications?

    Do you have any other health problems?

    Do you suffer from depression?

    Do you suffer from anxiety or stress?

    Do you suffer from Irritable Bowel Syndrome?

    Do you have any phobias?

    Do you smoke cigarettes?

    What is your current weight?

    What is your target goal?

    Signature:

    Date: