HEALING FOR YOU a friend or loved one To request a healing, please fill in all information below and click the Submit button. REGISTRANT INFORMATIONFirst Name * Last Name * Maiden Name (if different from Last Name) Parent / Guardian or Health Advocate Date of Birth * City of Birth* State of Birth * Country of Birth * GENDER *MaleFemaleCONTACT INFORMATION / REGION OF RESIDENCE At least one means of contact is required in order to communicate about any updates to your or the healing recipient's condition.CITY * STATE * COUNTRY * E-MAIL* PHONE NUMBER (optional) HEALTH CONDITION INFORMATION Please provide the following information of the health condition to be treated: - symptoms - progression of the condition - medical diagnosis - treatment received to date - current medications - you must indicate the condition that is most critical that you want us to focus on - we address one medically diagnosed ailment at a time for maximum effectiveness In order to proceed with the healing work please submit a good quality, recent digital photograph of the person for whom a healing is requested - the photo must be clear and not have any filter effects applied. The photo may be added at the time you fill out the Request a Healing form.Upload In order to proceed with the healing work please submit a good quality, recent digital photograph of the person for whom a healing is requested - the photo must be clear and not have any filter effects applied. The photo may be added at the time you fill out the Request a Healing form.Upload Only fill in if you are not human Reset
