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Please print this Brain Therapy Certification
Form and follow instructions:
You can use this space to track your patients' forms by putting marks or numbers after each of the categories. Adults Children Other Children's Conditions Please print clearly or type the information requested below: Your Name:________________________________________ Address: _________________________________________ City/State/ZipCode:_________________________________ Telephone: (h)______________________________ (w)_______________________________ E-Mail Address: ___________________________________ Age: __________ Profession ________________________ How many years in this profession: ________________ Please submit this form, the required
date for certification, and a check made out for $90
to: Before you mail everything, please check the website and call Terri for any changes in this information. For the option of having your practice
information on the website in the certified practitioners'
section, this fee is $75. I will give you the web person's information when
I send the certificate to you. The maximum cost of
certification would be $165.
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| To learn more about brain therapy for children and adults, contact Dr. Gillespie's office:
Main Line Medical and Wellness, 645 Clark Avenue · King of Prussia, PA 19406, phone: 1-610-265-2522 Copyright 1999-2006, Dr. Barry R. Gillespie all rights reserved |