Treatment Request Fax Form

If this is an emergency then it would be faster to use the Phone Treatment Method.

Please fill out this form First then print out and Fax to me at:  64 33142241

I charge a fee of $90 NZ (Approx $66.50 US) per treatment. This includes remedies and time upto 1 hour.

All fields marked * are required to be filled in. 

Your Contact Details


*Full Name:
*Full Address 
Please include postcode/zipcode & State (province):
*Country:
*Email Address: 
I may need to ask for further information.
*Phone Number:
Fax Number (if available please supply):

Your Animals Symptoms


Your Animals Name or Herd ID:
Animals - Type & Breed:
(eg. Dog: Greyhound, Cat: Siamese, Bird: Budgy etc.)
Animals Age:
Animals Sex:
Animals Symptoms:
( Please give a detailed description)
Has your animal been seen by a vet?:
If Yes what was the diagnosis?:
Is your Animal Eating?:
What kind of food does it eat?:
Is your Animal Drinking?
Your Animals Health history :
Is this an Acute condition?:
(Serious or sudden condition, endangering animal)
Is this a Chronic condition? 
(Developing over a long period of time):


 
 

CONDITIONS OF SERVICE AGREEMENT

REFUND POLICY

Due to the nature of my work I am unable to offer refunds for Healing Treatments.

CANCELLATION POLICY

I will attune to your animal and if I cannot help with a treatment I will not charge your Credit Card.
If this is the case I will send you an email to this effect.

DISCLAIMER

The price advertised may not be the same price charged to the Credit Card account due to exchange rate fluctuations. This means that because we are based in New Zealand, we have to convert your purchase price to New Zealand Dollars at the http://www.westpactrust.co.nz  exchange rate on the day it is processed. 

* Checking this box is an Acceptance of the above conditions of service: 

Credit Card Details


*Card type:
*Card Number:
*Card Expiry Date: Month Year 
*Name on Card:
Cost  for this Treatment: $90 NZ (Approx $66.50 US)