top of page
Family Portrait

Client Application

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

We are offering $500 off the Lyme Laser Home Protocol™ - Simply fill out the application form below by February 14th to claim this offer.

On completion of this form, a member of our team will be in touch to book your free, no obligation consultation.

About you

*Required field

State
Sex
Have you been professionally diagnosed with Lyme disease?
Yes
No
How long do you believe you've had Lyme?
Have you taken antibiotics as part of your Lyme treatment?
Yes
No
Have you engaged in other Lyme treatments?
Yes
No

What are your top three (3) symptoms? (please rate the severity from 1 to 10; 10 being the most severe)

Have you had any surgeries?
Yes
No
Do you have any metal (screws, plates, etc.) in your body?
Yes
No
Are you pregnant or plan on getting pregnant in the next 6 - 12 months?
Yes
No
Do you have a pacemaker?
Yes
No
Are you taking any prescription medications?
Yes
No
Are you taking any supplementation / vitamins?
Yes
No
Do you have any dietary restrictions?
Yes
No
Are you considering a multi-person treatment protocol? If so we will require those individual's details at the initial consultation.
Yes
No

GENERAL QUESTIONS

The following questions apply to all applicants:

Are you planning to take a vacation in the next 6 - 12 months?
Yes
No
Unsure
Are you interested in our finance options?
Yes
No

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

​*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

  • Instagram
  • Facebook
  • Youtube
bottom of page