Nectar "T"

hat die Fähigkeit  zu verzögern den Fortschritt

  von Muskeldystrophie und Multiple Sklerose

                                           (Nach Patienten Berichten)

TERMS OF SUBSCRIPTION
 
Completion of Medical Records
 
These personal details will be at the disposal of MD doctors who may be interested to observe your situation in relation with the Nectar "T" daily nutrition .
Please read this brochure carefully
If you don't understand any of the symptoms, put an X in the blank space
 
Name:
SurName:
Occupation:
Sex: Male     Female
Country/State:
Address:
Birth Date:
E-mail:
Mobile Number:
Fax Number:
Disease:
Case of Disease:
Year of The First Symptoms of the Disease:
YOUR HOMEOPATH
(IN CASE YOU FOLLOW HOMEOPATHIC REMEDIES ):
Allergy you may have:
Notes (Please write your personal comments):