Confidential Application Form to obtain your Personal Withdrawal Programme-
Your Name plus address or location (address is optional)
What Product are you taking?
How much of the Product do you take each day/each week?
How long have you taken it for?
What did you originally purchase the Product for, to treat?
Do you currently take any other over-the-counter, or prescribed Drugs or medications?
Do you currently drink Alcohol regulary? If so, how much per day/ per week?
Do you take any illegal drugs or products?
Have you any history of alcoholism, drug addiction, or any Mental Illnesses?
Are you allergic to any drug or products?
How did you become aware of Over-Count and its' services?
Do you intend to complete the Withdrawal Programme with the help of a Professional, eg Doctor ?
Copy and Paste your answers into an email, and send your Application to :-
[email protected]
PLEASE NOTE : Due to demand, we normally only write out personalised Withdrawal Programmes on Tuesday evenings only- you can expect to receive your Programme first thing on Wednesday morning.
What Product are you taking?
How much of the Product do you take each day/each week?
How long have you taken it for?
What did you originally purchase the Product for, to treat?
Do you currently take any other over-the-counter, or prescribed Drugs or medications?
Do you currently drink Alcohol regulary? If so, how much per day/ per week?
Do you take any illegal drugs or products?
Have you any history of alcoholism, drug addiction, or any Mental Illnesses?
Are you allergic to any drug or products?
How did you become aware of Over-Count and its' services?
Do you intend to complete the Withdrawal Programme with the help of a Professional, eg Doctor ?
Copy and Paste your answers into an email, and send your Application to :-
[email protected]
PLEASE NOTE : Due to demand, we normally only write out personalised Withdrawal Programmes on Tuesday evenings only- you can expect to receive your Programme first thing on Wednesday morning.