Center for
Oriental & Harmonic Medicine
Susan B. Goldstone
L.Ac, Dipl.Ac, LMBT, MA

Acutonics® Registration Form

To register please print out this page, complete and mail to:

Susan B. Goldstone, L.Ac
Center for Oriental & Harmonic Medicine
990 Lytchfield Place
Winston Salem, NC 27104

Make checks payable to: Center for Oriental & Harmonic Medicine. You may also call (336) 760-3993 to register with Visa or MasterCard. Email your registration information to sgoldstone@triad.rr.com.

Please note: this email address is not secure. You may not want to email your credit card information.

Please Choose Below

Acutonics®I: Sound Gates to Meridian Harmonics _______	Acutonics®II: Higher Harmonics and the Inner Nature of Tone ________	Acutonics® III: Harmonic Attunement _____	Acutonics® IV: Advanced Harmonic Applications ______
Acutonics®: Energetics of Points and Meridians _______	Acutonics® VI: Case Studies, Clinical Documentaries ________	Acutonics® VII: Harmonic Pathology _________	Acutonics® VIII: Thesis_________
Acutonics® I & II Intensive_______		Acutonics® III & IV Intensive_______

Class Dates:___________________________________
Name:________________________________________
Address:______________________________________
Email Address:_________________________________
Phone: Business______________________ Cell:________________________ Other:_______________________
Payment (circle one): Check MasterCard Visa
Credit Card Number_______________________________
Expiration Date:______________Amount of Payment $_____________
CCV(3 digit security code on back of card)____________
_____I would like to purchase the book and/or forks from you prior to seminar
_____I will wait to purchase the book and forks at the seminar
_____Undecided

Cancellation Policy: A non-refundable processing fee of $50.00 will be charged in the event of cancellation more than five (5) weeks prior to the first day of class. 65% of tuition costs will be refunded in the event of cancellation more than seven (7) days but less than five (5) weeks prior to first day of class. No refunds are available in the event of cancellation seven (7) days or less prior to first day of class. All monies will be refunded by check.