Pain Registration - Hypnosis by Doctors :Hypnosis by Doctors

Pain & Migraine Registration

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

Date*
MM slash DD slash YYYY
First Name*
Last Name*
DOB*
MM slash DD slash YYYY
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!

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name

WEIGHT LOSS

PAIN & MIGRAINE

STOP SMOKING

ANXIETY & DEPRESSION

ALCOHOL & DRUGS

GAMBLING

Now You Have a Choice

Register For Screening At Home

Dr. Clinton W. Smith, Psy.D

Clinical Psychologist & Hypnotherapist

For Assistance:

Call Us: 334.213.0054
Email Us: DrClintonwSmith@gmail.com
Office Address: 495 St. Luke Drive Montgomery, AL 36117

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