Click here to open PDF of form. Please print this form, fill out, and send it to the address below.
Include a copy of your last tax return, insurance information and a photocopy of a photo ID. (Drivers license is acceptable)
Visionary Alternatives, Inc: 1279 W Palmetto Park Road #3645
Boca Raton, FL 33486-3301
We are presently unable to fund any treatments due to lack of funding. Raising awareness about the effectiveness of alternative treatments is our only hope. Thank you.