Self-Hypnosis for Patients with Cancer and Chronic Illnesses Name * First Name Last Name Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * MM DD YYYY Emergency Contact name and phone number * How did you hear of this class Checkbox * Registering as a Participant ( Cancer Patient) $225.00 Registering as an Observer (Caregiver) $100 Name of enrolled patient for whom I am a caregiver Medical Diagnosis and when diagnosed Current and planned medical treatments Hopes and Goals for Using Self-Hypnosis * Fees to be paid through Zelle or Venmo Pay via Zelle to Wellness Consultants International 919 403-7229 Or in Venmo Business Accounts go to: @MedicalHypnosisConsultants Thank you!
