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7 Scott Rd, Hampton, NH 03842

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Home Protocol
Intake Form

Welcome to the Lyme Laser Home Protocol™ - It's now time to take your assessment.

Step 1 - Complete the form below

Step 2 - Once you have completed and submitted the form, you will be directed to a 'Book a free consultation' page please schedule a time and date that works for you.

Lyme Laser™ Intake form

First name*

Last name*

Email*

Phone*

Address*

Zip Code

City*

Date of birth*

Month

Day

Year

Sex*

Male

Female

Marital status*

Partners name

Number of children*

Referral code

History

Have you ever been professionally diagnosed with Lyme?*

Yes

Have you ever been professionally diagnosed with Candida?*

Yes

Have you ever been professionally treated for Candida?*

Yes

Have you ever taken antibiotics for 2 weeks consecutively or longer?*

Yes

Have you ever taken steroids for 2 weeks consecutively or longer?*

Yes

Do you feel these treatments were successful?*

Yes

Do you remember being bitten by a tick?*

Yes

Do you remember having the 'bullseye' rash?*

Yes

Do you have any other rash?*

Yes

Spend time in Tick-infested area?*

Yes

Frequent outdoor activities?*

Yes

Have you previously been on any lyme treatment programs?*

Yes

Do you have any pets?*

Yes

If so, what and how many?

Are you currently on any lyme treatment program?*

Yes

Successes*

Failures*

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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Home Protocol Intake Form

Lyme Laser™ Intake form

History

Home Protocol
Intake Form