Request Account - Masters-Center BodySmart Wellness Hypnotherapy Philip Holder PhD Wing Chun Certification Marie Holder MD Psychiatry Medical Hypnotherapy Certification Medical

Account Request Form

Request for a username & password.

Please select the checkbox(es) that apply to you. * Required
- Current Patient or Client (Therapy, Counseling, Hypnotherapy, Life Coaching, etc.)
- North American Wing Chun Association Member
- Online Training and Certification Programs
- Customer (Previous or Current Consumer of our Online Media, Text, etc.)
- First Time Request - Other
Name * Required
First Last
Gender * Required
- Male
- Female
Date of Birth * Required
MM slash DD slash YYYY
Email * Required
Phone Number (Cell Phone Preferred) * Required
Address * Required
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Please Clearly Explain The Reason For Your Request: * Required
Driver's License/Government-Issued ID * Required
Max. file size: 512 MB.
Some of our programs, courses, sessions etc. require that individuals be 18 years old or older. If younger, written permission from a parent or guardian must be provided. Please provide proof of age by attaching a copy of your Driver's License or other Government Issued Photo ID. You may also attach any other small files that you have been asked for by our office.
CAPTCHA

If you need help in attaching the file, please follow these simple instructions:

Take A Photo With Your Smartphone:
Take a picture of your ID with your phone.
Save it to your photos folder.
Open your phone’s browser to this page.
Attach the photo from your photos folder.

From A File On Your PC:
Scan a photo to your computer, or in some other way, download a picture file of your ID.
Open this page on your browser.
Browse to the location of your photo of your ID
Attach the photo and send.