623 W. Union Blvd. #3 Bethlehem, PA |
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Please fill out the Questionnaire and we will contact you for your
Special Consultation
at our office.
*
First Name
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Last Name
*
Email
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Phone
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Street Address
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City
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State
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Zip Code
#1
Do you have a problem with fatigue?
Yes
No
If so, what is your level of fatigue?
-Please select one-
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#2
Do you have trouble sleeping?
Yes
No
If so, how disrupted has your sleep been?
-Please select one-
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#3
Do you have bowel or digestive problems?
Yes
No
If so, how disrupted has your bowel function been?
-Please select one-
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#4
Do you have trouble losing weight?
Yes
No
#5
How long do you think you've been suffering with Thyroid symptoms?
#6
How has your life changed since your Thyroid began to be a problem?
#7
Since you've suffered from your Thyroid, what three things have you missed doing the most?
#8
Are you a smoker?
Yes
No
#9
How committed are you to getting into our program, reversing your Thyroid problem naturally and improving your health?
-Please select one-
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10
(on a scale of 1-10, with 1 being little commitment and 10 being full commitment)
#10
When is the best time to call you?
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Home
Oxygen Therapy
Two Free Visits
FAQ
Testimonials
Contact Us
Meet Dr. Benedetto
Bethlehem Thyroid Relief
Dr. Ray Benedetto
623 W. Union Blvd. #3
Bethlehem, PA
(610) 974-9911