Contact | FibroFree

Date

Name

Address:

Postal Code:

Phone Number:

Home:

Cell:

Work:

Email Address:

Occupation:

Age: (optional)

Do you want to be added to Fibrofree's monthly meeting reminder list?

Yes
No

Would you be willing to release your phone number and email address to others in the group if they request it?

Yes
No

Are you under the care of a physician?

Yes
No

Have you received a formal diagnosis of Fibromyalgia?

Yes
No

Have any family members been diagnosed with fibromyalgia?

Yes
No

Are you on the guai protocol?

Yes
No

Have you found your cycling/therapeutic dose?

Yes
No

If yes, what is your cycling/therapeutic dose

Are you HG?

Yes
No

Are you on the strict diet?

Yes
No

Liberal?

Yes
No

****Please note all membership information will remain strictly private & confidential and will not be released to anyone unless you give us authorization to share it with others. If you provide us permission to use or disclose any information, including medical information about you, you may revoke that permission at any time.

This Recovery Group can only help you with questions concerning salicylates and guaifenesin. IT IS NOT MEANT AS A SUBSITUTE for your Physician’s advice. We cannot advise you about other conditions or medications you are taking.

If you change your email address, please remember to let us know to keep the monthly newsletter available to you. You can be deleted from the email list at your request anytime.

Registration

If yes, what is your cycling/therapeutic dose