Name *

First Name

Last Name

Phone *

Country

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###

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Date of Birth *

Month/Date/Year

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you take any prescription drugs? *

Yes

No

Do you have any history of contagious disease(s)? *

Yes

No

Do you have a history of serious physical injury? *

Yes

No

Do you have a history of psychological disorder? *

Yes

No

Are you currently pregnant? *

For females that are currently pregnant or may be currently pregnant, please check "yes". For everyone else, please check "no".

Yes

No

Do you smoke? *

Yes

No

Diet *

Non-Vegetarian

Vegetarian

DISCLAIMER *

I, the recipient, understand that Pranic Healing is not meant to replace conventional medicine but rather to complement it. If symptoms persist a medical professional is to be consulted immediately. I hereby release the person(s) providing the Pranic Healing and the Pranic Healing organization from any liability as the result of the services received by me.

I Agree

I Disagree

Please submit name as an electronic signature below. *

First Name

Last Name