COMA COMMUNICATION - Reservation Coma Communication and Process-oriented facilitators deal with patients, health practitioners, caregivers, and families - Victoria, BC, Canada
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Appointment Reservation Form

1   My name is:

2.  My E-mail address:
We will not share your e-mail address, nor use it for any purpose other than answering your specific questions.  Give a phone number if you would prefer to be contacted by phone.

3. My Phone number (OPTIONAL):

4. I wish to reserve (give further details in #8 below)
Consultation    
Counseling  
Training Session

5. For this number of people:

6. I want the session on this date:

                     

7. I want the session to start at this time:

    

8.   Do you or any of those accompanying you have any special requirements, or any requests/questions/comments?   If so, please type them below.

 

         
THANKS!!!  Please Click on the "Submit" Button below.  We will get back to you as soon as possible via e-mail or phone to confirm your reservation.

              
 


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