Please fill out and submit this form. Don't hesitate to reach out to us if you have any questions.

Submitter of distance healing request *

Email address *

Phone *

Is this a cell number *

Yes

This distance healing request is for *

Myself

Another person

Person receives healing *

Located at *

Distance Healing Policy

Informed consent to receive Holy Fire® Reiki distance healing. Please read and check the box to affirm your consent.
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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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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, we will issue a refund for the remaining days.
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By checking this box, I have read and agreed to comply with Dharma Reiki & Acupuncture's payment and refund policy.

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

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Privacy Notice and Consent for Electronic Submission of Form
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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 agreed to fully 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.
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Date * +