1 on 1 Meeting

The information you provide below is totally secure and private. We ask these questions only to understand where you are at and to offer a better healing path.

Name *

Last Name *

Email *

Take a selfie of yourself only with your eyes open

A picture of yourself

Type of diabetes *

Type 1

Type 2

Type 3

Onset diabetes age *

Which of the following vaccines have you taken in the last 6 years? *

COVID

FLU

Allergies

None

Other vaccine

If COVID: Why? please explain

Do you have any other illnes *

Yes

No

Which one? please explain:

Are you using any of these drugs *

Sugar

Heroin

Cocaine

Cigarettes

Canabis

Alcohol

None

Any other drugs?

Reason for contacting us *