Symptom Survey
Tissue Mineral Analysis
Telephone Consultation
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SERVICES

PATIENT INFORMATION FORM


Last Name:  
First Name:  
Address:  
Address2:  
City:    State:    Zip:  
Home Phone:  
Work Phone:  
E-mail:  
Sex:  
Birthdate:    
Would you like your report via email  
If no, your report will be sent via USPS mail

Please send a check or money order for
$100.00 US Funds for Mineral Analysis
or $80.00/per hour US Funds for Telephone Consultations

Mailing address for payment:
Dr. Eva Urbaniak
P.O. Box 31051
Seattle, WA 98103-1051

If you have questions for Doc Eva, please feel free to email her at docevaonline.com

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