Pain Registration - Hypnosis by Doctors - It Works Quickly Anywhere! :Hypnosis by Doctors – It Works Quickly Anywhere!

Pain & Migraine Registration

Register & Pay $35 for An Intro Phone Therapy Session or An Office Consultation

First Name*
Last Name*
DOB*
Date Format: MM slash DD slash YYYY
Age*
Marital Status*
Occupation*
Email*
Phone*
Office Consultation Fee*
Price: $35.00
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*

American Express
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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

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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