gerson home set-up training application form.pdf

info@ 葛森家居設置及培訓申請表格 Gerson Home Set-Up Training Application Form 此應用程序只應由患者本身填寫（而不是由朋友或親戚）。 This application should only be filled out by the patient themselves (not by a friend or relative). 標有星號（* ）的字段是必需的。 Fields marked with an asterisk ( * ) are required. 姓名* / Name* ______________________________________________________ 電子郵件* / Email* ______________________________________________________ 主要電話號碼* Primary Phone Number* _____________________________________________________ 地址* Address* 中國China ___________________________________________________________________ 香港Hong Kong ___________________________________________________________________ 台灣Taiwan ___________________________________________________________________ 1 info@ 你是如何知道葛森療法？* / How did you hear about the Gerson Therapy?* 從朋友或親戚 /From a friend or relative 葛森療法的紀錄片/ Documentary about the Gerson Therapy 醫生/ Doctor 在線/ Online 書/ Book 其他/ Other ______________________________________________ 性別* / Gender* 男/ Male 女/ Female 年齡* / Age* _______________________________ 高度(厘米)/ Height (cm) ____________________________ 重量（磅）/ Weight (lbs) ____________________________ 2 info@ 病歷和資料Medical History and Information 你有癌症嗎？* Do you have cancer?* 有/ Yes 無/ No 目前診斷* / Current diagnosis* _________________________________________________________________________ 診斷日期：* / Date of diagnosis:* ___________________________________