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Search for:
HOME
TESTIMONIALS
RESEARCH
HOME PROTOCOL & LOCATIONS
ARTICLES
CONTACT
HOME
TESTIMONIALS
RESEARCH
HOME PROTOCOL & LOCATIONS
ARTICLES
CONTACT
Home Protocol Application
elise wine
2024-01-02T09:30:05-05:00
LYME LASER PROTOCOL™
New Client Application
LLHP™
How did you hear about the Lyme Laser Protocol™ (LLP™)?
*
Referral by Customer
Referral by Employee
Referral by Affiliate
Referral by External (Non-Customer)
Social Media
Reviews
Word of Mouth
Online Research
Lyme Support Group
Advertisement (print)
Advertisement (online)
Signage (location drive by)
Webinar / Teleconference
Name of the person / company who referred you (if applicable):
How many of you are interested in doing the LLP™ together?
*
1
2
3
4
5
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
Address
Address
City
City
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
Email
*
Phone
*
Date of Birth
*
Sex
*
Female
Male
Other
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?
*
Less than 1 year
1 - 2 years
2 - 5 years
5 - 10 years
10+ years
Have you taken antibiotics as part of your Lyme treatment?
*
YES
NO
If yes, for how long?
*
1 - 10 days
2 - 4 weeks
2 - 6 months
6 - 10 months
12+ months
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
*
1
2
3
4
5
6
7
8
9
10
#2
*
Rating
*
1
2
3
4
5
6
7
8
9
10
#3
*
Rating
*
1
2
3
4
5
6
7
8
9
10
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
Address
Address
City
City
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
Email
*
Phone
*
Date of Birth
*
Sex
*
Female
Male
Other
Relationship to other applicants
*
Family
Friend
Have you been professionally diagnosed with Lyme disease?
*
YES
NO
Date of Diagnosis
*
How long do you believe you've had Lyme?
*
Less than 1 year
1 - 2 years
2 -5 years
5 - 10 years
10+ years
Have you taken antibiotics as part of your Lyme treatment?
*
YES
NO
If yes, for how long?
*
1 - 10 days
2 - 4 weeks
2 - 6 months
6 - 10 months
12+ months
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
*
1
2
3
4
5
6
7
8
9
10
#2
*
Rating
*
1
2
3
4
5
6
7
8
9
10
#3
*
Rating
*
1
2
3
4
5
6
7
8
9
10
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
Address
Address
City
City
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
Email
*
Phone
*
Date of Birth
*
Sex
*
Female
Male
Other
Relationship to other applicants
*
Family
Friend
Have you been professionally diagnosed with Lyme disease?
*
YES
NO
Date of Diagnosis
*
How long do you believe you've had Lyme?
*
Less than 1 year
1 - 2 years
2 -5 years
5 - 10 years
10+ years
Have you taken antibiotics as part of your Lyme treatment?
*
YES
NO
If yes, for how long?
*
1 - 10 days
2 - 4 weeks
2 - 6 months
6 - 10 months
12+ months
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
*
1
2
3
4
5
6
7
8
9
10
#2
*
Rating
*
1
2
3
4
5
6
7
8
9
10
#3
*
Rating
*
1
2
3
4
5
6
7
8
9
10
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
Address
Address
City
City
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
Email
*
Phone
*
Date of Birth
*
Sex
*
Female
Male
Other
Relationship to other applicants
*
Family
Friend
Have you been professionally diagnosed with Lyme disease?
*
YES
NO
Date of Diagnosis
*
How long do you believe you've had Lyme?
*
Less than 1 year
1 - 2 years
2 -5 years
5 - 10 years
10+ years
Have you taken antibiotics as part of your Lyme treatment?
*
YES
NO
If yes, for how long?
*
1 - 10 days
2 - 4 weeks
2 - 6 months
6 - 10 months
12+ months
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
*
1
2
3
4
5
6
7
8
9
10
#2
*
Rating
*
1
2
3
4
5
6
7
8
9
10
#3
*
Rating
*
1
2
3
4
5
6
7
8
9
10
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
Address
Address
City
City
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
Email
*
Phone
*
Date of Birth
*
Sex
*
Female
Male
Other
Relationship to other applicants
*
Family
Friend
Have you been professionally diagnosed with Lyme disease?
*
YES
NO
Date of Diagnosis
*
How long do you believe you've had Lyme?
*
Less than 1 year
1 - 2 years
2 -5 years
5 - 10 years
10+ years
Have you taken antibiotics as part of your Lyme treatment?
*
YES
NO
If yes, for how long?
*
1 - 10 days
2 - 4 weeks
2 - 6 months
6 - 10 months
12+ months
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
*
1
2
3
4
5
6
7
8
9
10
#2
*
Rating
*
1
2
3
4
5
6
7
8
9
10
#3
*
Rating
*
1
2
3
4
5
6
7
8
9
10
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:
*
Still evaluating my Lyme
Exploring LLHP™ as treatment option for the future (not ready yet)
Exploring LLHP™ as an immediate treatment option (one of several options)
Ready to start healing
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.
Drop a file here or click to upload
Choose File
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
Address
Address
City
City
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
Email
*
Phone
*
Relationship to applicants:
*
Family
Friend
Caregiver
Other
Name
Name
First
First
Last
Last
If you are human, leave this field blank.
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