General Registration - Hypnosis by Doctors :Hypnosis by Doctors

General Registration

You will be contacted for an appointment when we receive your completed form.

Chronic Pain • Weight Loss • Stop Smoking • Excessive Drinking • Drug Abuse • Break Ups
Phobias • Gambling • Depression • Stress • Memory Improvement

Please review the testimonials after submitting your form.

Date*
Month
Day
Year
First Name*
Last Name*
DOB*
Month
Day
Year
Age*
Marital Status*
Occupation*
Email*
Phone*
Consultation Fee*
Price:
Once you make this payment complete the second half of the form that asks details about your lifestyle problem. All information is confidential and only seen by Dr. Smith.
Credit Card*
WE DO NOT RETAIN CREDIT CARD INFORMATION!

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Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Please Return to the Registration Page and See Testimonials Before Your Appointment.

WEIGHT LOSS

PAIN & MIGRAINE

STOP SMOKING

ANXIETY & DEPRESSION

ALCOHOL & DRUGS

GAMBLING

Dr. Clinton W. Smith, Psy.D

Clinical Psychologist & Hypnotherapist

For Assistance:

Call Us: (334)233-5610
Email Us: DrClintonwSmith@gmail.com
Office Address: 495 St. Luke Drive Montgomery, AL 36117

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