How did you hear about the Lyme Laser Protocol™ (LLP™)? *

Name of the person / company who referred you (if applicable):

How many of you are interested in doing the LLP™ together? *

Are you interested in doing the Lyme Laser Protocol at one of our locations? *

YES

NO

APPLICANT #1: This person will also be the primary contact for this application

First Name: *

Last Name *

Address *

Address

City

State/Province

Zip/Postal

Email *

Phone *

Date of Birth *

Sex *

Have you been professionally diagnosed with Lyme disease? *

YES

NO

Date of Diagnosis (Approximate Date Is Ok) *

How long do you believe you've had Lyme? *

Have you taken antibiotics as part of your Lyme treatment? *

YES

NO

If yes, for how long? *

Have you engaged in other Lyme treatments? *

YES

NO

Please explain. *

Why are you interested in the LLHP™? *

What are your top three (3) symptoms? (please rate the severity from 1 to 10; 10 being the most severe)

#1 *

Rating *

#2 *

Rating *

#3 *

Rating *

Have you had any surgeries? *

YES

NO

Please provide details. *

Do you have any metal (screws, plates, etc.) in your body? *

YES

NO

Please provide details. *

Do you have a pacemaker? *

YES

NO

Are you pregnant or plan on getting pregnant in the next 6 - 12 months? *

YES

NO

Are you taking any prescription medications? *

YES

NO

Please list name(s). *

Are you taking any supplementation / vitamins? *

YES

NO

Please list name(s). *

Do you have any dietary restrictions? *

YES

NO

Please provide details. *

APPLICANT #2:

First Name: *

Last Name: *

Address *

Address

City

State/Province

Zip/Postal

Email *

Phone *

Date of Birth *

Sex *

Relationship to other applicants *

Have you been professionally diagnosed with Lyme disease? *

YES

NO

Date of Diagnosis *

How long do you believe you've had Lyme? *

Have you taken antibiotics as part of your Lyme treatment? *

YES

NO

If yes, for how long? *

Have you engaged in other Lyme treatments? *

YES

NO

Please explain. *

Why are you interested in the LLHP™? *

What are your top three (3) symptoms? (please rate the severity from 1 to 10; 10 being the most severe)

#1 *

Rating *

#2 *

Rating *

#3 *

Rating *

Have you had any surgeries? *

YES

NO

Please provide details. *

Do you have any metal (screws, plates, etc.) in your body? *

YES

NO

Please provide details. *

Do you have a pacemaker? *

YES

NO

Are you pregnant or plan on getting pregnant in the next 6 - 12 months? *

YES

NO

Are you taking any prescription medications? *

YES

NO

Please list name(s). *

Are you taking any supplementation / vitamins? *

YES

NO

Please list name(s). *

Do you have any dietary restrictions? *

YES

NO

Please provide details. *

APPLICANT #3:

First Name: *

Last Name: *

Address *

Address

City

State/Province

Zip/Postal

Email *

Phone *

Date of Birth *

Sex *

Relationship to other applicants *

Have you been professionally diagnosed with Lyme disease? *

YES

NO

Date of Diagnosis *

How long do you believe you've had Lyme? *

Have you taken antibiotics as part of your Lyme treatment? *

YES

NO

If yes, for how long? *

Have you engaged in other Lyme treatments? *

YES

NO

Please explain. *

Why are you interested in the LLHP™? *

What are your top three (3) symptoms? (please rate the severity from 1 to 10; 10 being the most severe)

#1 *

Rating *

#2 *

Rating *

#3 *

Rating *

Have you had any surgeries? *

YES

NO

Please provide details. *

Do you have any metal (screws, plates, etc.) in your body? *

YES

NO

Please provide details. *

Do you have a pacemaker? *

YES

NO

Are you pregnant or plan on getting pregnant in the next 6 - 12 months? *

YES

NO

Are you taking any prescription medications? *

YES

NO

Please list name(s). *

Are you taking any supplementation / vitamins? *

YES

NO

Please list name(s). *

Do you have any dietary restrictions? *

YES

NO

Please provide details. *

APPLICANT #4:

First Name: *

Last Name: *

Address *

Address

City

State/Province

Zip/Postal

Email *

Phone *

Date of Birth *

Sex *

Relationship to other applicants *

Have you been professionally diagnosed with Lyme disease? *

YES

NO

Date of Diagnosis *

How long do you believe you've had Lyme? *

Have you taken antibiotics as part of your Lyme treatment? *

YES

NO

If yes, for how long? *

Have you engaged in other Lyme treatments? *

YES

NO

Please explain. *

Why are you interested in the LLHP™? *

What are your top three (3) symptoms? (please rate the severity from 1 to 10; 10 being the most severe)

#1 *

Rating *

#2 *

Rating *

#3 *

Rating *

Have you had any surgeries? *

YES

NO

Please provide details. *

Do you have any metal (screws, plates, etc.) in your body? *

YES

NO

Please provide details. *

Do you have a pacemaker? *

YES

NO

Are you pregnant or plan on getting pregnant in the next 6 - 12 months? *

YES

NO

Are you taking any prescription medications? *

YES

NO

Please list name(s). *

Are you taking any supplementation / vitamins? *

YES

NO

Please list name(s). *

Do you have any dietary restrictions? *

YES

NO

Please provide details. *

APPLICANT #5:

First Name: *

Last Name: *

Address *

Address

City

State/Province

Zip/Postal

Email *

Phone *

Date of Birth *

Sex *

Relationship to other applicants *

Have you been professionally diagnosed with Lyme disease? *

YES

NO

Date of Diagnosis *

How long do you believe you've had Lyme? *

Have you taken antibiotics as part of your Lyme treatment? *

YES

NO

If yes, for how long? *

Have you engaged in other Lyme treatments? *

YES

NO

Please explain. *

Why are you interested in the LLHP™? *

What are your top three (3) symptoms? (please rate the severity from 1 to 10; 10 being the most severe)

#1 *

Rating *

#2 *

Rating *

#3 *

Rating *

Have you had any surgeries? *

YES

NO

Please provide details. *

Do you have any metal (screws, plates, etc.) in your body? *

YES

NO

Please provide details. *

Do you have a pacemaker? *

YES

NO

Are you pregnant or plan on getting pregnant in the next 6 - 12 months? *

YES

NO

Are you taking any prescription medications? *

YES

NO

Please list name(s). *

Are you taking any supplementation / vitamins? *

YES

NO

Please list name(s). *

Do you have any dietary restrictions? *

YES

NO

Please provide details. *

GENERAL QUESTIONS

What are your top three (3) questions about the LLHP™?

#1 *

#2 *

#3 *

Are any members of the application planning to take a vacation in the next 6 - 12 months? *

YES

NO

UNSURE

Will any members of your party require financing? *

YES

NO

Goal of application: *

We encourage you to upload any/all information or documentation that you feel can help us as we review your application and prepare for your assessment/consultation. Examples: Blood tests, Lyme tests (positive and negative), current/previous treatment plan, your Lyme story, etc.

Maximum file size: 516MB

Contact information, please contact applicant #1 (primary applicant): *

YES

NO

If NO, provide contact information below:

First Name: *

Last Name: *

Address *

Address

City

State/Province

Zip/Postal

Email *

Phone *

Relationship to applicants: *

Name

First

Last

LYME LASER PROTOCOL™

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