Intake form
Email address *
Your Full Name *
This appointment is for *
Email *
Phone number *
Current occupation *
Age of Subject of this session *
Current condition and/or symptoms of the subject of this session.Please rate each symptom on a scale of 1-10, with 10 being the worst. *
Anything else about your situation that you think is important: *
Please list on a separate line all current diagnosis, current prescriptions or treatments for each.
Pranic healing is not a replacement for current medical system. Its complementary therapy. (submitting this form will mean that you agree with the above declaration)
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