Feeling Fat, Fuzzy, or Frazzled
   
 

Practitioner Referral Form

Please fill out completely.
Fax a copy of your license to Dr. Shames at 707 792-9733.
As soon as we receive completed form & copy of your license you will be added to our referral list.

This information will not be given out except in the context of referral to your practice, it will not be shared otherwise.

Name:
License type/#
   
City:
State:
Zip Code:
   
Phone: ext.
Email:
Website:

30 word description of your practice, expertise related to hormone balance

Special Interest / Training:

Yes No -- Have you attended one of our practitioner seminars?

Yes No -- Would you like to attend one of our seminars?

Yes No -- Would you like to sponsor a seminar in your area?

Yes No -- Would you like to receive our Newsletter?

Yes No -- Would you like postcards for our book?

If yes put your mailing address below and # postcards to send you:
Address:
Amount::

Yes No -- Would you like to order bulk copies of our book wholesale?

Please enter the words in the box below:

I certify that I am a licensed health practitioner in good standing with my licensing board.

Signature:

 
 


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