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We offer payment plans for your wellness

7 Scott Rd, Hampton, NH 03842

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Book a free appointment

To get started we kindly request that you complete our new client application form. Please note that the form is quite detailed, but it plays a crucial role in our initial triage process, allowing us to tailor your support to best suit your individual needs

On completion of this form, a member of our team will be in touch as soon as possible.

About you

First name*

Last name*

*Required field

Address*

City*

Zip *

State*

Phone

Email*

Date of birth*

Sex*

Have you been professionally diagnosed with Lyme disease? *

Yes

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

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

Yes

Have you engaged in other Lyme treatments? *

Yes

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

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

Yes

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

Yes

Do you have a pacemaker? *

Yes

Are you taking any prescription medications? *

Yes

Are you taking any supplementation / vitamins? *

Yes

Do you have any dietary restrictions? *

Yes

Are you considering a multi-person treatment protocol? If so we will require those individual's details at the initial consultation.*

Yes

GENERAL QUESTIONS

The following questions apply to all applicants:

Are you planning to take a vacation in the next 6 - 12 months? *

Yes

Unsure

Are you interested in our finance options?*

Yes

We will review your medical history, including any documentation, as part of your initial consultation.

Book Now

*The Lyme Laser Protocol™ and all variants of the Lyme Laser Protocol™ are a Complementary and Integrative Health Protocol as defined by the National Institutes of Health (NIH). The Lyme Laser Protocol™ is designed to address and alleviate Lyme disease symptoms.

7 Scott Rd, Hampton, NH 03842

833.ZAP.LYME (927.5963)

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