Please complete and submit this form. We'll get back to you as soon as possible to discuss further details.

Submitter of healing request *

Email *

Phone mobile *

This healing request is for *

Myself

Another person

Who is the healing for *

Where *

Consultation date 1st choice * +

Time 1st choice *

Consultation date 2nd choice * +

Time 2nd choice *

Additional requests or comments

Distance Healing Policy

Please read and check all the boxes below.

Informed Consent for Holy Fire® Reiki Distance Healing
*

I, the submitter of this distance healing request, have been informed that Holy Fire® Reiki distance healing is a safe energy healing modality. I understand that Holy Fire® Reiki distance healing does not replace the medical treatment or advice of my physician or the physician with whom the recipient of this distance healing request is under care. I understand that it is my responsibility to inform my physician or the physician of the recipient of this distance healing request about Holy Fire® Reiki distance healing. If I or the recipient of the distance healing have any issues or concerns at any time during the course of the distance healing, I understand that it is my responsibility or the recipient's responsibility to immediately contact and inform Dharma Reiki & Acupuncture clinic. I understand that this distance healing request, whether for myself or on behalf of someone else, is voluntary and I, or the recipient of the distance healing, have the right to discontinue the distance healing at any time and for any reason by giving Dharma Reiki & Acupuncture clinic a written cancellation notice.

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Payment and Refund
*

Distance healing must be prepaid. No refund for payment once healing is sent. If healing is canceled before the prepaid duration of service is completed, a refund will be issued for the remaining days. I affirm that I have read and agree to comply with Dharma Reiki & Acupuncture's payment and refund policy.

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Minimum Age Requirement
*

The submitter must be at least 18 years of age to request and consent to receiving Holy Fire® Reiki distance healing. I affirm that I am at least 18 years of age.

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Privacy Notice and Consent for Electronic Submission
*

By checking this box and my electronic signature below, I consent to the transmission of this form and all information in this form electronically. I understand that Dharma Reiki & Acupuncture does not share, sell, rent, or trade any 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 distance healing by phone, email, or in person.

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By signing this form electronically, I affirm that I have read and agree to comply with all parts of the Distance Healing Policy. I understand that my electronic signature is legally binding as defined by the Federal ESIGN Act.
*

Date signed * +