Devmani Reiki - Patient Registration Form, udaipur, ray key, india, karuna reiki, the art of living, music therapy, color therapy, acupressure,

1.	Just for today, I will live by the Attitude of gratitude.
2.	Just for today, I will not worry.
3.	Just for today, I will not get angry.
4.	Just for today, I will earn my living honestly.
5.	Just for today, I will honour my parents, Teachers and elders.

Patient Name : * Dr. Mr. Miss Mrs.


Last Name *	First Name *	Middle Name
Date of Birth *	Day Month Year
Address : *
Phone No. (Resi.) (Office) (Mobile)
Email : *
Age : *	Sex : Marital Status
Problem *
Since When *	Reason *
Allergies (if Any)
A Brief History
Questions about life style (More emphasis on thoughts)
Medical Confirmations
Doctor's Name	Contact No.
Description of Doctor's Diagnosis
Medication

Registration for * Acute Chronic patient on

as a * Fresh Repeater patient.

Enclosed Herewith Rs.* By * Cash Cheque No.

Dated

Drawn on as * advance Full Registration Fee.

Balance Amount of Rs.* will be sent by Date*

Terms & Conditions :*

If you are intending to take treatment for any ailment (By Touch Therapy or by Distance Therapy), please note that:-

1. Your treatment is on your request; the therapist is not responsible for results.
2. Time of treatment may extend from the expected time.
3. The fee for treatment will be charged in advance (On weekly basis.)
4. You will have to abide with instructions given during therapy period

I Agree to the Terms & Conditions stated above.

Enter Verification Code:

Swami Jeevan Devmani
Traditional Reiki Grand Master, Therapist & Teacher
Usui Shiki Ryoho
Traditional & Natural Healing Centre,
Dev-Vila, 65-A, Kharol Colony,
Fatehpura, Udaipur - 313004. Rajasthan, INDIA
Phone no. (91-294) 2450177 (R), 2451389(O)
Mobile No.91-9352516130
Web Site - www.devmanireiki.com
E-mail: - swamijeevandevmani@yahoo.co.in
Account No. ICICI Bank - 004501015417