Application form

* Name and Surname:

* Nationality:

* Your age:

* Residence:

Please give details of your complaints, pain, sensations and their duration

Do you have a diagnose and what is it?

How long have you been suffering from the disease?

Was any other treatment given and what was it?

What was the effect of the previously applied treatment?

Do you believe in complementary and alternative methods of treatment?

Do you believe that your health problem can be resolved/treated/healed?

How did you hear about "Chi Net Project"?

Do you have any other diseases? Please describe them in the same manner as the first one

Kindly attach a recent picture of yours:

* e-mail:

Skype:

I join the 'Chi Net Project' at my own discretion and responsibility.