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This form serves as your initial contact with us, whether you are requesting
a free case evaluation, submitting a consultation request,
or completing your intake form.
We will let you know which stage applies to you.
We typically respond within 24 hours, depending on time zone differences.

If you require urgent medical care, please contact your local emergency services or healthcare provider immediately.

Medical Information Form

Select Intake Form

Your First and Last Name

If the request is for someone other than yourself, fill out this section with the patient's information.

Patient First and Last Name

Gender

MaleFemale

Date of Birth

Country of Residence

Phone Number with Country Code

Email Address

Are you currently under medical supervision?

YesNo

Primary Condition or Concern

Maximum 250 words.

How long has this situation been ongoing?

Have you used the Free Earth Energetics Treatment?

YesNo

Why do you feel ready to engage in this process at this time?

Upload Relevant Medical Records

Drop files here or click to browse

Max size: 10 MB

Accepted formats: PDF, JPG, PNG, DOC. Maximum 10MB per file.

How did you hear about Usman?

All information submitted in this form will be handled with discretion and confidentiality, and reviewed solely for the purpose of evaluating your request. Information supplied is transmitted securely using Secure Sockets Layer (SSL) encryption. SSL uses a public key contained in this site's security certificate to protect all data transmitted, including personal details, contact information, and medical records. For more information, visit sectigo.com.

“Seeing my patients recover and regain their health is the ultimate gift.”

Usman Baloch

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This form is SSL encrypted. Your data is transmitted securely.

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Medical Information Form

What happens next

Payment