SpaceAge Consultation Form

Name:

Sex:
Male
Female

Phone #:

Address:

Address 2:

City:

State/Province:

Zip/Postal Code:

Country:

Your E-mail:

Type of Request:
Online E-mail Consultation
Skype Audio Consultation
Skype Video Consultation
Telephone Consultation
(Please provide Patient Name, address, Tel. No., e-mail address, if different from above, Skype ID and convenient time for voice or video call)

Insert your Medical history and health goals in the space provided below:

Do not exceed 1000 characters.

Billing Particulars:
Name on Credit Card:

Billing Address:

Address 2:

City:

State/Province:

Country:

Zip/Postal Code:

Billing Phone:

E-mail Address:

Credit Card:

Credit Card Number:

Expiration Date:

CVV:

Please follow these instructions if you need a detailed Consultation by Phone or Skype (audio or video) or through E-mail:

Prior to your consultation, please complete our standard Questionnaire and e-mail back to us with copies of your old and new Medical Reports and Blood Tests if readily available. A short note on your Medical history, health challenges and future goals will be helpful.

Please download the Questionnaire by clicking on the link given below:

http://www.space-age.com/Questionnaire.doc

Also enclose a complete list of medications and supplements you have been on in the past and are presently taking. Send E-mail to: consult2008@space-age.com

This will enable us to guide you better.

On receipt of your Questionnaire, we will get in touch with you for a mutually convenient time for a consultation.