REGISTRATION FORM
(Please Print)
Today’s date: Form No:
PATIENT INFORMATION
Mr. Miss
Patient’s Last name: First: Middle:
Mrs. Ms. Photo
IN CASE OF EMERGENCY
Name of local friend or relative (not living at same address): Relationship to patient: Home phone no.: Work phone no.:
( ) ( )
The above information is true to the best of my knowledge. I am aware of the treatment process and providing my / patients reports and photograph for
convenience of distance healing
Minor Chakras
Congested Normal Depleted Over active Normal Underactive
Congested Normal Depleted Over active Normal Underactive
Congested Normal Depleted Over active Normal Underactive
Congested Normal Depleted Over active Normal Underactive
Congested Normal Depleted Over active Normal Underactive
Congested Normal Depleted Over active Normal Underactive
Congested Normal Depleted Over active Normal Underactive
Congested Normal Depleted Over active Normal Underactive
Congested Normal Depleted Over active Normal Underactive
Congested Normal Depleted Over active Normal Underactive
Congested Normal Depleted Over active Normal Underactive
Congested Normal Depleted Over active Normal Underactive
Congested Normal Depleted Over active Normal Underactive
Congested Normal Depleted Over active Normal Underactive
Organs
Liver Congested Normal Depleted
Stomach Congested Normal Depleted
Small Intestine Congested Normal Depleted
Large Intestine Congested Normal Depleted
Left Kidney Congested Normal Depleted
Right Kidney Congested Normal Depleted
Left Lung Congested Normal Depleted
Right Lung Congested Normal Depleted
Congested Normal Depleted
Congested Normal Depleted
Congested Normal Depleted
Congested Normal Depleted
Congested Normal Depleted
Congested Normal Depleted
Congested Normal Depleted
Congested Normal Depleted
Congested Normal Depleted
PRESCRIPTION
Prescribed Healing 3 Times a Week for Next 2 Weeks
Suggested Forgiveness and Mercy Prayer During Healing
Patient Testimonial
Name
Address
Age
Occupation
Case
Healers
Period dd/mm/yyyy to dd/mm/yyyy
Testimonial
Signature
Signed On