Program Registration

 

Please complete the form below. Once submitted, you will receive 21 days of helpful emails aimed at keeping you focused and motivated.   Daily communication is our commitment to you.

 

First Name

Last Name

Address

City, ST, Zip

 

Country

 

Home Phone

Cell Phone

 

Email

Confirm Email

 

__ 18-22 23-27 28-32 33-37 38-42 43-47 48-52 53-57 58-62 63-67 68-72 73-77 78-82 Age

__ Male Female Gender

__ White Black American Indian Asian Indian Chinese Japanese Hispanic Mexican Puerto Rican Central/South American Cuban Race

 

__ Weight Loss Program Smoking Program What Service?

__ LA Bodyart LA Henry Fitch, DC LA Ken Pace, DC LA Mannino's LA Michael Graham, MD LA Michelle L. Leblanc, DC LA Lisa Colon, MD LA Physiofit LA Tony Macalouso, PT What provider treated you?

 

Today's Date

Treatment Date

 

The 6 questions below are for the Smoking Program Only.

__ 1-2 3-5 6-8 9-12 13-15 16-20 21-25 26 or more How many years have you smoked?

__ 1-5 cigarettes a day 6-10 cigarettes a day 11-15 cigarettes a day 16-20 cigarettes a day 21-25 cigarettes a day 26-30 cigarettes a day 30-35 cigarettes a day 36-40 cigarettes a day 2 1/2 packs a day 3 packs a day 3 1/2 packs a day 4 or more packs a day dipper How many cigarettes do you smoke daily?

__ yes no Does your spouse smoke?

__ yes no Do any of your children smoke?

__ yes no Did your parents smoke?

__ yes no Are you pregnant?

 

The data contained in this form will be used in an I.R.B. (Independent Review Board) study to track the results of this program.  All personal data is confidential and secured.  The results will be used for data tracking only.  FRESH START Laser Therapy Centers LLC has the right to use this data as needed to complete the I.R.B. study including periodic follow-up telephone calls.  Success is not guaranteed with this program. This is simply a guide to a better and healthier life.

I have read the above statement and completed the above form to the best of my knowledge.

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