| This form may be completed by those who have received healing through a Spiritualist Healer, whether the healing was physical, mental or spiritual. This may refer to a single healing, several healing's or absentee healing. Thank you. Name of Spiritual Healer: ___________________________________________________ Name of person who received healing: ________________________________________ Address: _________________________________________________________________ Email Address: ____________________________________________________________ Date(s) of healing: _________________________________________________________ Specific healing condition treated: ____________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Result(s) of the healing(s): __________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Signature of Patient: _________________________________________ Date: _________ Subscribed and sworn before me this: __________ day of ______________ , 2________ My commission expires: ___________________________________ SEAL Notary Public: ___________________________________________ |
|---|