EmailMeForm
Stop Smoking in 3 Easy Steps
Kindly complete the info below and click submit at the end. If these times do not suit you, kindly contact me on 079 868 9694
Name
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First
Last
Mobile Number or WhatsApp:
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Home/ Business Contact Number:
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Date of Birth:
Married/ Divorced/ Single:
Dependents:
Occupation:
Email
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Please choose a day that will suit you:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
*This is for your first consultation where we will establish the level of Tired Mind Disease (TMD) and design a personalised treatment.
Please choose a time that will suit you:
9am
10:30am
12 Noon
1:30pm
3pm
I need an early evening slot.
*Please note that these times are estimates and can be structured around your schedule as well.
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