* Full Name:

* Address:

* City:

* State:

* Zip Code:

* Country:

* Home Phone No.

* Work Phone No.

* e-mail:

* URL:

I would like to book/confirm
the following inclusive dates
available from the calendar:

* Date From:

* Date To:

To confirm your dates,
the (Clinic Organizer) must
agree to pay a non-refundable
booking fee of $ 150.00 .
You must mail your check at
the time you forward this form.

Your booking will be confirmed
when your check clears.
Thank you.

Insert you full name indicating
you agree to these terms.

* Sign - Your Full Name:

= Very Positive

= Positive

= Neutral

= Negative

= Very Negative