"Ask Your Questions Form"
Please fill in the appropriate information below so we may better serve you
WELCOME! - To Your New Found Health

First Name:

Last Name:

Enter Email Address:
NOTE: Make Sure YOUR EMAIL is correct. Check it before clicking on "Submit"
3. What is most important to you at this time?

4. What health problems do you have?

5. What have you done to correct this?

6. What herbal products are you interested in?

7. Would you like Dr. Miles to contact you by phone? If yes, please check this box:
8. Phone Number: (Optional) format: 555-666-7777

Dr. Miles is only available to call you 9:00 AM to 5:00 PM CST Monday through Friday

Best Day To Call:



Best Time of Day:

to
9. Would you like to be on our mailing list? If yes, please check this box:
10. Do you have any additional comments or questions?

11. How did you find Dr. Miles Site?:
(select the appropriate one(s))

    Search Engine
    Magazine Ad
    Newspaper Ad
    Web Classified Ad
    Message Board
    News Group
    Friend
    Family Member
    Other
    Please explain "Other" here:

    


Thank You!


Contact

James E. Miles, N.D.
1811 North Austin Avenue, Suite. 203
Georgetown, Texas 78626
(512) 868-9867
Fax (512) 868-9847
toll free: 1-877-844-HERB (4372)
Email:
jmiles@theherbdoctor.org
located north of Austin
in central Texas