Vedic Healing: Consultation Request Form

Spiritual Counseling Request Form

Please provide the following contact information:

* Required Fields
Current Client?	Yes No
*Full Name*	*
*Sex*	Male Female
*Street Address*	*
*Address (cont.)*
*City*	*
*State/Province*	*
Zip/Postal Code	*
*Country*	*
Home Phone	*
*Work Phone*
*Cell Phone*
*E-mail*	*

Payment will be made:

Send Paypal payments to home@vedichealing.com

Make checks payable to Madhavi Rathod. All checks require two weeks to clear. You will be provided with an address where you may mail your check.

How did you hear about VedicHealing.com?

Questions/Comments:

Please provide some information about which areas of your life in which you desire assistance.

If you must re-schedule your appointment, you must provide at least 48 hours notice in advance of your scheduled time. Without adequate notification, your account will be charged in full for the session. We do not provide refunds for any services. By clicking below, you agree to these conditions.

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