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| Do you have a current passport? | |
| Have you traveled outside of USA? To which country? | |
| First, Middle, Last Name as appeared in your passport or Birth Certificate | |
| Current Address, city, state and zip code, Country | |
| Home Phone | |
| Work Phone | |
| Cell Phone | |
| Email | |
| To work around the time zone, when is the earliest time in the morning and the latest time at night we can call you? | |
| What Medical concerns do you have? Please specify some major symptoms | |
| What major Medical Treatments/Procedures are you considering? | |
| What Minor Treatments/Procedures are you considering? | |
| Would you consider Traditional Chinese Medicine or Other Alternative Treatment as the Main method of treatment or Supplemental Treatment? | |
| When do you plan to travel to China to receive the treatment? | |
| How long do you plan to stay in China? 2 weeks? 3 weeks 4 weeks? Or 5 weeks? | |
| Will you have any companions to travel with you to China? How many people? | |
| Would you like to add a vacation to your stay? | |
| A side trip to nearby tourist attractions ? Yes No | |
| A post recovery stay at a Spa, Resort or Hotel? Yes No | |
| Visit a wellness center? Yes No | |
| Why are you considering abroad treatment? (check all that apply) Lower Cost Care? Yes No | |
| Alternative Treatment? Yes, No | |
| High Quality, Personalized Care ? Yes, No | |
| Ability to get treated more quickly? Yes, No | |
| Anonymity ? Yes, No | |
| Opportunity to couple treatment with a vacation ? Yes, No | |
| Other? | |
| How would you pay for your treatment? Cash, Credit Card, Debit Card, Insurance reimbursement ,Financing through Loan, or Other? | |
| Your Birth Year? | |
| How Did You Find Out About Us ? | |
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