SVHR Prayer Request
Date ___/____/____
Name ____________________

If Minor, Name of Parent _____
Address: __________________
Phone ____________________
Street and # _______________
City State Zip ______________
E-Mail ____________________

First Time Visitor (Y/N) _____
How did you hear about the Healing Rooms? __________

Appointment Preference: Morning ____ or Evening ____
1st Choice _______
2nd Choice _______
3rd Choice _______

Prayer Need _______________
Under Doctor care (Y/N) _____

Liability Release (Please read)
I, the undersigned do hereby release Healing Rooms and their volunteers or staff from any harm or perceived harm resulting from my voluntary receiving of free prayer on this and subsequent visits. I understand that these Healing Rooms are staffed by volunteers representing the broad body of Christ and reflect many denominations and churches. They are not trained or licensed professionals of counseling, therapy or medical services. I understand that if I am currently taking medication, or operating under the advice of a professional service, I will allow them (my medical doctor, therapist, counselor etc.) to confirm any results of prayer received before altering any prescribed course of action. I understand that this form and all data recorded on it is the sole property of Healing Rooms. All content will be held in confidence for the sole purpose of ministry to the above.

Signed ___________________
Date ___/____/____