Healing Registration Form


KINDLY FILL DETAILS OF PERSON WHO REQUIRED HEALING.

EMAIL ID

FIRST NAME

LAST NAME

FATHER'S / HUSBAND'S NAME

DATE OF BIRTH

GENDER

MOBILE NUMBER

ALTERNATE NUMBER

YOUR ADDRESS

CITY / TOWN

STATE / PROVINCE

COUNTRY

POSTAL / PIN CODE

PROFESSION / DESIGNATION

HOW DID YOU HEAR ABOUT US?

SELECT OPTION/S

₹₹ ENERGY EXCHANGE METHODS ₹₹

FEES PAID (IN TOTAL)

SCREENSHOT OF PAYMENT
Attach the screenshot of online payment below or send it to the official Whatsapp number "9873029525" or on email id "healingservices@usuireiki.in" for confirmation.

DESCRIBE PROBLEM

ADD PHOTO
(Add Picture of Person Who Required Healing.)

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