Reservation

Address*

Date of Birth of Reiki recipient*

Select the type of Reiki treatment, and your request for Hands-on, Distance or House Visit*

For PeopleFor PetsFor Concerns (only distance healing)Request for Hands-on ReikiRequest for Distance ReikiRequest for House visit (transport fee of $35 per visit)

What are you/the recipient seeking Reiki Treatment for?

General HealthRelaxationStress ReductionEmotional HealingInsomniaPain ManagementSurgerySupport for Other TreatmentsReiki for Concerns/SituationsI am purchasing a Reiki Gift Certificate (Please specify treatment duration, hands-on/distance healing, self-collection, digital copy of gift certificate below)

1. For whom is this treatment for? Include all names, and your relationship to the Reiki recipient(s).

2. Briefly describe the condition, situation or event for which you are requesting Reiki for.

3. Describe your/the recipient’s health condition. Provide a brief medical history of the Reiki recipient; please include specific details (e.g. cancer, diabetes, eczema, high blood pressure, allergies, rheumatoid arthritis)

4. Provide further medical information: current medication, scheduled surgery (type/date), lifestyle factors (e.g. smoking, drinking, eating, exercise, sleep)

5. What emotional challenges are you/the recipient currently working on (e.g. as a result of physical ailments/challenges)?

6. Do you understand that Reiki practitioners cannot guarantee any benefits you/the recipient might receive from Reiki therapy? Reiki goes to where it is most needed and it is your inner wisdom who decides how to use the Reiki energy for your highest good.*

Yes, I understandNo, this is not clear to me

7. If you are applying for distance Reiki: do you have a photograph of your face/the recipient’s that you can email to me? (If so, please email it to relax@reikimoment.com with the recipient's full name in the subject line of the email).

Yes, I will email a photographNo, I don’t have a photograph

8. Would you like to receive occasional emails about upcoming promotions and news from A Reiki Moment?*

Yes, I would like to receive occasional emails from A Reiki MomentNo, I do not wish to receive any information and promotions

BY APPOINTMENT ONLY
Thank you for completing your online application form. Please note that all reservations made through this form is subject to availability and does not guarantee your appointment slot. Kindly wait to receive an email confirmation from relax@reikimoment.com about the availability of your preferred date and time. Do remember to check your spam/junk folders too! Once we have agreed on a time, please go to the Shop Here page to proceed with your payment prior to your treatment time.