M.E.L. - San Jose - COMPLEMENTARY MEDICINE
Distant Healing Registration Form
  
 

Distant healing can be arranged at the M.E.L. - San Jose Center, or by filling in the following form. An UE practitioner will be assigned to provide distant healing within 24 hours from the date submitted.

Please fill in as much information as possible. The data will be kept confidential for statistic and research studies purpose.
Note: Patient's Number comprises of first 4 letters of first name, and last 4 digits of phone number.

* indicates required field
 

 
Date: *
  
 
Patient Number:
  
 
First Name: *
  
 
Middle Initial:
  
 
Last Name: *
  
 
Date of Birth: *
  
 
Gender:
  
 
Address: *
  
 
City: *
  
 
State/Province: *
  
 
Country: *
  
 
Home Phone:
  
 
Work Phone:
  
 
Occupation:
  
 
E-mail: *
  
Currently under physician care?:
  
 
Physician Phone:
  
 
Physician Address:
  
Medical Diagnosis:
  
Symptoms (description, severity): *
  
Current medication (name, dosage):
  
Please list any other forms of treatment modalities you are currently utilizing (i.e. chiropractic, homeopathy, energy work, meditation, acupuncture, etc.):
 
Referred to us by: Physician Friend Family Brochure Website
 
 
Referred to us by other:
 
 
Universal Energy Trained?: If yes, Level?: Date Completed:
 

Therapy Results: Mankind Enlightenment Love - San Jose Center would like your comments to assist us in our on-going quality improvement efforts. Please come back to this web page and fill out the below survey after each treatment period of 10 days. If we don't hear from you after the first ten days, we'll assume that you don't require further treatment, we would not start the second ten days.


Healing Period
Improvement Percentage
Comments
First 10 days
 0% 10% 30% 50%
70% 90% 100%
Second 10 days
 0% 10% 30% 50%
70% 90% 100%

Disclaimer:

I, * , hereby consent to participate in the healing method of Universal Energy (UE) free of charge. I understand that the UE healing is a non-invasive, energy-based complementary therapy to conventional medicine, and is not intended to replace medical treatment.
I certify that no verbal, written, explicit, or implicit promise has been made to me to guarantee that participation in this therapy implies success in the relief and/or cure of illness or disease.
I further understand that data generated from my participation in this program may be used for research studies involving the efficacy of UE healing method, and my participation in the program is voluntary.

By submitting my healing request to Mankind Enlightenment Love - San Jose Center, I have read this disclaimer and agree to relieve Mankind Enlightenment Love - San Jose Center from all of liabilities.

 

 

Last Udated: Wednesday, March 28, 2001
Send comments to: web-admin