COMA COMMUNICATION - Inquiry Form Coma Communication and Process-oriented facilitators deal with patients, health practitioners, caregivers, and families - Victoria, BC, Canada
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SERVICES INQUIRY FORM

to request an Appointment - click HERE

We will reply via e-mail or phone with Price, Availability,
or any other information you request.

Request customized information about our services using this 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'm interested in information about your services for this sort of patient (NOTE: you may select more than one dropdown item while depressing keyboard CTRL button):

Coma  Advanced Dementia
"Vegetative State" Traumatic Brain Injury
Memory Loss Other (Give details in box below)

5. Patient Services:

6. Training Services:

7. Counseling Services:

8. Education / Speaking:

9.   Space to describe in more detail what you are looking for.  If you require face-to-face contact, please tell us where we could meet you:
 

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

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