Please print this form and send it to your nearest White Eagle Centre.
Date: ..........................................................
Patient's Surname: Mr/Mrs/Miss/Ms .............................................................................
First Name(s): .................................................................................................................
(If pronunciation is likely to cause difficulty, please give phonetic pronunciation of the name).
Approximate age: ...............................
Is the patient receiving medical treatment?: YES/NO
Person to whom correspondence is to be sent:
Mr/Mrs/Miss/Ms ..............................................................................................................
Address: ..........................................................................................................................
.................................................................................................... Post Code: ..................
Please Note: If you are requesting healing for someone other than yourself, please confirm with a tick here that they wish to receive it:
If correspondence is to go to them, please write your name and address below:
Mr/Mrs/Miss/Ms ................................................................................................................
Address: ............................................................................................................................
...................................................................................................... Post Code: ..................
Symptoms or complaint: ...................................................................................................
.........................................................................................................................................................
I enclose a stamped, self addressed envelope and/or a donation to help maintain the healing work. Thank you.
© All rights reserved.
|
Top
|