PLEASE DO NOT USE THIS FORM FOR CORRESPONDENCE. THIS FORM IS FOR RECEIVING ADDITIONAL TRAINING INFORMATION FROM US. CORRESPONDENCE CAN BE SENT TO [email protected] THANK YOU. First Name* Last Name Name First Name Last Name E-mail* I am a: (choose best answer)* Medical PractitionerMedical StudentPatientHolistic Medicine Enthusiast Type of Practitioner Credentials - APCredentials - BSNCredentials - CACredentials - DCCredentials - DMDCredentials - DOCredentials - DOMCredentials - DVMCredentials - FNPCredentials - LAcCredentials - MDCredentials - NDCredentials - NPCredentials - PACredentials - PTCredentials - RNCredentials - VMD Type of Practitioner DCMDNDPTLMTDORNODOTLAcDPTCNHPDOM Country* United StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCuraรงaoCyprusCzech RepublicDemocratic Republic of the CongoDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNagorno-KarabakhNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandTurkish Republic of Northern CyprusNorthern MarianaNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRepublic of the CongoRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSouth SudanSpainSri LankaSudanSurinameSvalbardeSwatiniSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTransnistria PridnestrovieTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsIsle of ManUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabwe Street Address City State Zip Mail Address: How did you hear about FSM? (please check ALL that apply)* Referral (please tell us who referred you below)Conference (please tell us which one below)WebinarRead The Resonance Effect BookRead FSM in Pain Management TextbookGoogle SearchTwitterEmail List MemberFacebook AdFacebook PageYouTube VideoTownsend Letter Magazine Who referred you to Frequency Specific? What topics are you most interested in? (choose up to 3) How Does FSM Work?Who Can Learn & Use FSM?FSM Training OptionsTime & Costs To Start Using FSMIncreasing ATPNerve PainTreating FibromyalgiaChronic Pain - (Myofascial Pain, Scar Tissue, Disc, Facet, Ligament laxity, Shoulder, Knee, Arthritis...)Post-surgical RecoveryPTSDShinglesNeuropathic PainRSD / CRPSSports Injuries & EnhancementReducing InflammationScar Tissue and AdhesionsEquipment Used For FSMCEU's - Continuing Education UnitsVestibular InjuriesThalamic Pain SyndromePeripheral NeuropathiesDigestive - (IBS, Chrohn's, UC)Gallbladder, GoutSkin Anti-agingKidney & Kidney Stone PainReproductive System (Ovary, Uterus, Prostate)Respiratory System (Asthma, Bronchitis, COPD)Cardiovascular System (CAD, CHF)Endocrine System (Adrenals, Thyroid, Breast)Acupuncture to FSM Translation Mail Information Packet To: Street Address Street Address Line 2 City State / Province Postal / Zip Code I would like information on how FSM can help with: (choose up to 3) Anti AgingAchilles TendinitisAdhesionsAsthmaBack PainBell's PalsyBenign Prostatic Hypertrophy (BPH)BronchitisCarpal TunnelChronic Regional Pain SyndromeConcussionEmotional IssuesEndometriosis Fibromyalgia Associated With Cervical Spine InjuryFibrosisFracturesFrozen SholderGoiterGoutHerpesInflammationInterstital CystitisIrrital Bowel SyndromeKidney Stone PainLymphedemaMigraine HeadachesMyofascial PainOsteoarthritisNerve PainNeuromuscular Pain And InflammationPeripheral NeuropathyPost-Herpetic Neuralgia Post Surgical PainPost Traumatic Stress DisorderReflexive Sympathetic Dystrophy (RSD)Restless Leg SyndromeScar TissueSciaticaShinglesSinusitisSpinal Disc PainSports InjuriesSprains/StrainsTemperomandibular Joint (TMJ)PainTendon and Ligament Injury or PainTension HeadachesTennis ElbowVulvodyniaWhiplashWound Healing Note Send me updates on future events . Updates Send me updates on future eventsSubmitShould be Empty: