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Intake Form

Health Declaration

Please fill out the following health declaration form in order to receive an energy healing session.

First Name

Last Name

Email

Have you had any cold or flu like symptoms in the past 2 weeks?

No

Yes

Do you have an existing medical conditions including any mental illnesses?

Date

Initials

I confirm that the information given in this form is true

Thanks for submitting!

Contact

befreehealing.au@gmail.com

17 Panorama Terrace,

Greenpoint, NSW 2251

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Be Free Healing

Green Point

New South Wales

Australia

Your Name

Your Email

Phone

Message

Thank you, I'll be in touch shortly.