HEALING PRAYER FORM

Name *

Email Address

Age

Gender *MaleFemale

Mobile Contact

Country

Nationality

Hometown

Name of Sickness *

Description of Sickness *

How did the sickness started? *

Have you visited any of these persons or places as a result of your sickness? *Medical Doctor,Man of God,Herbalist,Traditional healer,Malam/Islamic healer,Witch doctor,Fetish priest,spiritualist,others

others

Have you visited any of these persons or places as a result of your sickness? *HospitalClinicChurchCrusadeTemplePrayer -CampHealing CenterShrineForestRiver sideSacred placeothers

others

When did the sickness started?

What were you asked to do when you visited any of these persons or places? *

Duration of sickness[Years] From:

to

Medical Doctor’s report *

What the sick person has not been able to do as a result of the sickness *

Have you accepted Jesus Christ to become your personal Savior?YesNo

If YES when ?

If YES what is the PROOF or EVIDENCE ?

Date *