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Personalized Body Dowsing  / Client Profile

 Welcome to the "Personalized Body Dowsing" Page.

 NOTE:  Unless you made special arrangements with Roger for payment. You MUST first make a payment for your "Personalized Body Dowsing" session before your Personalized Body Dowsing session can be processed.

 To make a payment within the USA only please click here

 International Payments cannot be made on this website. You must call  Roger at 1-808-855-8272 to make a payment over the phone.

 You can E-mail Roger at: yourbodycanheal@gmail.com to arrange a payment type.

After your payment is completed.

       Return to this page and fill out the "Client Profile" below.  Upon completion, submit the form back to Roger. 

 Roger will then complete your "Personalized Body Dowsing" evaluation.                      When completed, Roger will contact you by phone to give you the "Results of his Findings" 

Client Profile

Direction for filling out this form

If a topic below does not apply, please indicate it by typing in the box = "None"

 

When your form is completed click "Submit Form".

NOTE This same blank form will reappear on your screen.

DO NOT fill it out again.

Your "Client Profile" has been received at the Body Expressions office.

No Worries! The form you just filled out & submitted has been sent to Roger at yourbodycanheal@gmail.com

You DO NOT need to fill this form out again when it reappears.

* Required fields
E-mail Address *
First Name *
Last Name *
House / Business Street Address: *
Town / City / Area *
U.S.A. State
Country *
Zip Code / Postal Code
Today's Date: *
Phone:( Land Line )
Cell Phone Number
Skype number:
Gender: M / F *
Age: *
Weight:
Main Complaint's *
Operations or Organs removed during your lifetime *
Do you take Prescription Medications? What health condition are you taking the medication for: *
Supplements you are currently taking on a daily basis:
If you are currently taking a homeopathic remedy. List remedies and potency
IMPORTANT > Are you willing to take a supplement that may contain some animal by-product in the supplement, for a short period of time ?
Check Box if you DO EAT these foods below ?
Other Dietary Preferences / Explain
I have Dietary Restrictions or Food Allergies:> List them below *
Have you been vaccinated for Covid 19? If so, what Type of Vaccination: Modena, Pfizer, Johnson & Johnson? *
Additional Information Roger should know before testing you.
Your Electronic signature OR Type in your full name *


 

 

Click any of the links below to view additional pages and services offered by

Body Expressions 

808-855-8272

yourbodycanheal@gmail.com

                " Your Body has the Answer to Your Cure" ...   Roger                        

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