Thank you for your interest in Usui/Holy Fire III Reiki practitioner course. We would be glad to meet with you and discuss any inquiries that you may have about the course. Please submit this appointment request form and we'll be in touch with you as soon as possible.

First Name *

Last Name *

Email (please double check for accuracy) *

Phone *

Is this a cell number *

Yes

Consultation method, please check below *

Course consultation is given in-person only

Date of appointment - 1st choice * +

Time - 1st choice *

Date of appointment - 2nd choice * +

Time - 2nd choice *

Additional comment

------------------------

Privacy Notice and Consent for Electronic Submission of Form
*

By checking this box, I consent to the transmission of this form and all my information in this form electronically. I understand that Dharma Reiki & Acupuncture does not share, sell, rent, or trade any of my information in this form. I understand that this online form is serviced by Formsite and my data may be accessible by Formsite and their affiliates for the purpose of maintaining and regulating their services in accordance with their privacy policy. I understand that Dharma Reiki & Acupuncture has no control and no authority over the privacy policy and the usage of data collection of its online-service provider Formsite and any affiliates of Formsite. I understand that I have the options of requesting an appointment by phone, email, or in person.