Vedic Healing: Consultation Request Form

Jyotish Reading 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*	*

Please provide Birth Information:

Date of Birth (MM/DD/YYYY)	*
Birth Time (HH:MM)	* am pm
*Birth Place* (City & State)	*
Birth Country	*
*Birth Time Source*	*
*Other:*

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.

Reading will take place:
*

Has anyone else in your household ever had a reading with VedicHealing.com?

Yes No

If yes, Name:
Relationship:

How did you hear about VedicHealing.com?

Questions/Comments:

You may send a few specific questions to Madhavi in advance. Please make sure to e-mail your questions at least one week in advance of your reading to ensure that they are covered in your session.

If you must re-schedule your reading, 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 reading. We do not provide refunds for any services. By clicking below, you agree to accept these conditions.

© Copyright 2003, Madhavi Rathod - All Worldwide Rights Reserved.
All materials on this site are the exclusive property of Madhavi Rathod.
Contact owner of this site for permission to use materials in any form.