The Pecarvé Hypnotherapy Clinic

CONTACTING RUBIN PECARVÉ The Pecarvé Hypnotherapy Clinic phone: (514) 736-4444 - fax: (514) 736-0789 Fill in and send the information below.The Clinic will contact you within 72 hours. ** NOTE: PLEASE CALL THE CLINIC 48 HOURS IN ADVANCE IF YOU MUST CANCEL OR RESCHEDULE AN APPOINTMENT
Name:
Email address:
Occupation:
Phone Number:
How late may I return your call:
Age: Gender: Male Female

Brief description of the condition for which treatment is required
Have you had hypnotic therapy previously? Yes No
How did you hear about us?
** NOTE: APPOINTMENTS CANCELLED LESS THAN 48 HOURS IN ADVANCE ARE SUBJECT TO CANCELLATION FEE. PLEASE ADVISE US BY PHONE.

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The Pecarvé Hypnotherapy Clinic
phone: (514) 736-4444 - fax: (514) 736-0789