Name: *Mobile No: *Email:
Question 1 – Do you have any health issues such as 3 highs (high blood pressure, high blood glucose, high blood liqid)?
YesNo
Question 2 – Do you have Stomach pain/Stomach ulcer?
YesNo
Question 3 – Do you have heart disease?
YesNo
Question 4 – If a product which can active your cells and you can feel it around 7 minutes, will you give it a try?
YesNo
I understand and agree to try at my best willingness.