Release Form

Please fill out the following:
Your full name:
Address:
City:
State:
Zip Code:
Year:
Phone Number:(ex: 732-555-1234)
Cell Home
Male Female
Your e-mail address:
ex: relax@thedawnofanewage.com
@



I, the undersigned, understand that the Reiki session given is for the purpose of stress reduction and relaxation to promote healing. I understand that a Reiki session is not a substitute for medical or psychological diagnosis and treatment.

Reiki practitioners do not:
*Diagnose conditions
*Prescribe any form of medication
*Perform medical treatment
*Interfere with treatment from a licensed medical professional

It is recommended that I see a licensed physician or health care professional for any physical or psychological ailments that I may have.

Signature* ________________________________________(only if mailing it with a payment)

Date: (mm/dd/yyyy) / /



Mail*: Release form, Request form and check or money order to:
The Dawn of a New Age
821 Mantoloking Road
Brick, NJ 08723

*If using PayPal, your payment is your signature. It is not necessary to mail it to us, but please fill out the above form, so that your distant healing/prayer is sent to you with the proper intent to help you.


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