APPLICATION FORM TO OBTAIN YOUR OWN PERSONAL

WITHDRAWAL PROGRAMME -

       When you have completed Stages [1] and [2], which should take you just over a

fortnight to do, we will require more Information from you, before we can design your

personalised, main Stage [3], and send it to you.

 

 I normally write new Programmes out for Clients  ONLY  every Tuesday evening.

 

Some Web Browsers will allow you to copy and paste this page into a new Email message, so you can complete the required details. If not, either email us and ask for a Form to be sent to you to complete as an Attachment, OR simply copy the details yourself into an Email.   If you need help with it,  do phone Over-Count for assistance,  every Tuesday evening between 7pm till 10pm.

                                                                                            David Grieve.  September 2009 ©.

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CONFIDENTIAL.

 

  NAME :.............................................................................................

  ADDRESS :......................................................................................

                       .......................................................................................

                       ........................................................................  POST CODE: .........................

             TELEPHONE :......................................................................

 

OTC PRODUCT MISUSED :..................................................................................................

 

 HOW LONG HAVE YOU TAKEN IT FOR?  .....................................................................

 

 PRESENT QUANTITY TAKEN, ON AVERAGE, PER DAY OR PER WEEK?

        ..................................  Per DAY.                ................................................  Per WEEK.

 

ANY OTHER PRESCRIBED/ILLEGAL MEDICINES/DRUGS CURRENTLY TAKEN?

        ..........................................................................................................................................

 

DO YOU HAVE ANY ALLERGIES, DRUG SENSITIVITIES, ETC ?      Yes  /   No.

      If Yes, What are they?  ......................................................................................................

 

DO YOU REGULARY DRINK ALCOHOL?    Yes  /  No.

    If Yes, How much per Day? ...............  Per week, on Average? .............

 

HOW DID YOU LEARN ABOUT OVER-COUNT & IT’S SERVICES?

 

.....................................................................................................................

 

ANY OTHER MEDICAL CONDITION WE SHOULD BE AWARE OF ?

 

    .............................................................................................................................

 

 

      Please send me my personalised Withdrawal Programme, Stage [3],

 

SIGNED : ...................................................................   DATED : .............................

 

Please enclose a large, A4, 56p s.a.e. for your Reply, if using post, thank you.

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