CRM Mind and Body Health

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Patient / Customer Name * Email Address * Phone Number Payment For * — Select service — General Consultation Specialist Consultation Dialysis Treatment Lab Tests X-Ray / Imaging Pharmacy / Medication Procedure Deposit / Admission Myers Cocktail — J$25,000 Immune Shield — J$22,500 Glutathione Detox — J$15,000 Advanced Rehydration — J$12,000 Beauty and Radiance — J$18,000 NAD+ Renewal — J$28,000 Deposit Balance Payment Other Amount (USD) * Notes (optional)

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