Enrollment Form
I need to keep the details you submit for my own evidence only. They will not be disclosed to any other parties.
 

 

Fields marked with * are mandatory

Service I wish to enroll in:
One year treatment (includes six-month trial).
Payment for the whole year to be made at the beginning of the 7th month)
Mr/Mrs/Ms *
First Name *
Last Name *
E-mail *
(Please provide correct address)
Verify E-mail.
Please re-type your email.*
Treatment for *
If not for yourself, then please provide the name of the person you wish to enroll
Age of the patient *
Your problem and comments *
Telephone *
Country *
Address
By clicking the Submit button you agree to all conditions as described in Conditions page.
  

 

home  |  about epilepsy  |  my approach  |  non-obligatory trial  |  conditions  |  faq's  |  testimonials  |  links
Copyright © 2004-2006, Ivan Gellner