Name: Hypnosis by Doctors
Address: 495 St Lukes Drive, Montgomery, AL, 36117
Telephone: +13342130054
Price range: $

Pain & Migraine Registration

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*
WE DO NOT RETAIN CREDIT CARD INFORMATION!

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