Date of Birth

Patient Name (required)

Email (required)

Phone

Delivery Address

Step-1. Medical Symptoms.

DepressionSeizuresPainAnxietySpasmsPanic attacksJoint discomfortInsomnia/SleepingMemory LossHeadachesNervousnessStressO Neck or Back TraumaCramps

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Please tell us more details about specific medical conditions and any other information that might be useful for the doctor to make a decision.