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Your information will be sent to a Pranic Healer who will contact you to arrange a time for a distance healing. Pranic Healing can be done just as easily at a distance as in the same room. If you are not contacted within a week, please contact us on this form to find out what happened. We will make sure that you are contacted as soon as possible. Most healings are associated with a fee (click here for a list of fees).

Name:
Address:
City: State/Province:
Zip/Postal Code: Country:
Phone: Email:
Date of Birth: Age: Height: Weight:
Sex: Marital Status: Occupation:

Do you smoke?   Yes Rarely No
Do you drink alcoholic beverages?   Yes Rarely No
Do you take any drugs or perscribed medications?   Yes Rarely No
(if yes, please specify)
Do you have a history of contagious diseases?   Yes No
(if yes, please specify)
Do you have a history of serious physical injury?   Yes No
(if yes, please specify)
Do you have a history of phychological disorder?   Yes No
(if yes, please specify)
Are you pregnant?   Yes No
Do you have high blood pressure?   Yes No
Any other conditions?

What conditions would you like the healing for?