Please print out this form, fill it out to the best of your ability
and
fax to: 702-734-4786 or mail to:
QUESTIONNAIRE for Michael Stellitano
1555 E. Flamingo Road, Suite 429, Las Vegas, NV 89119
Please type or print clearly. Feel free to use the back if
necessary.
Name:_____________________________________________
Age:_____________
Address:______________________________________ Phone:________________
City:__________________________________ State:________ Zip:_____________
I heard about Michael
from:_______________________________________________
Reason for seeing Michael (Type of illness, pain, disease,
problem):______________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Describe your experience (s) during and after
treatment:________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Describe the
results:_____________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Comments:_____________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
SIGNATURE _________________________________________ DATE_______________
You may quote me: ___ USING MY FIRST NAME AND
INITIAL ___ USING MY FIRST NAME
