Back to Page

Innergy Healing Procedure© Order Form
For optimum results, please answer everything applicable as completely as possible

Please indicate your preferred form of response:
Telephone Mail Personal session (appointment required)

Your blood type
Frequently consumed foods
and drinks
List any over-the-counter remedies taken regularly
List any supplements being
taken regularly
List any and all prescribed
medications being taken
Specific relevant questions,
concerns or comments
Full name
Street address
Address 2
City
State    Zip code
Telephone (including area code)
Alternate phone #
Fax
E-mail
Web site URL