Application for Absent Healing
Please print this form and send it to your nearest White Eagle Centre.
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Date:..........................................................

Patient's Surname: Mr/Mrs/Miss/Ms .....................................................................................................................

First Name(s): .............................................................................................................................................................
If pronunciation is likely to cause difficulty, please give phonetic pronunciation of the name).

Approximate age: ............................... Is the patient receiving medical treatment?: YES/NO
Person to whom correspondence is to be sent:

Mr/Mrs/Miss/Ms ........................................................................................................................................................

Address: .....................................................................................................................................................................

..................................................................................................................... Post Code/Zip: ....................................
Please Note: If you are requesting healing for someone other than
yourself, please confirm with a tick here that they wish to receive it: ......................................................
If correspondence is to go to them, please write your name and address below:

Mr/Mrs/Miss/Ms .......................................................................................................................................................

Address: ....................................................................................................................................................................

.................................................................................................................... Post Code/Zip: .....................................

Symptoms or complaint: .......................................................................................................................................

......................................................................................................................................................................................

......................................................................................................................................................................................

......................................................................................................................................................................................
Please use space on the reverse of this form to continue, if needed.

I enclose a stamped, addressed envelope large enough to take the Lodge's A5 Healing Information Folder and/or a donation to help maintain the healing work. Thank you

FOR OFFICE USE:              GROUPS                 H2                 NLA