Refuah Shlaymah list
Name of ill person to be placed on the list *
Your answer
Is the ill person added to the list a Mishkan Torah member? *
Name of person who is making this request *
Indicate self if you are making the request yourself
Your answer
Relationship of the ill person to the individual making the request *
Indicate self if you are making the request yourself
Your answer
Short Term (4 weeks) or Long Term (12 weeks) *
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This form was created inside of Mishkan Torah Synagogue.