Distance Clearing & Healing Request Form Name of person ordering: Date What did you purchase? Single Week Multiple 2-26 Weeks* Emergency Single Week Emergency 4 Weeks *If you purchased Multiple Weeks 2-26—How many? Name of person who this service is requested for? One person, one pet at a time in each order please Age of That Person: Gender Identity—What pronouns will make the recipient's heart sing? Please include if person, animal, place, relationship or other below. Address of who service is requested for: City State ZIP/Postal Code Country We won't be contacting them, or sharing this information. Got it! On a scale of 1-10... 1 being worst, 10 being best, please rate present state of requestee 12345678910 If for a pet, what kind? Is this time sensitive? Yes No If time sensitive, please describe parameters: Reason you are requesting the Distance Clearing & Healing? If this is for a health or medically related request, please list any medications or supplements you are taking: What expectations do you have in regards to the Distance Clearing & Healing? What other information would you like to share from your heart about this that you feel will be important for Laura to know? How did you hear about Laura Scott's work? Referred by someone, I will list below so you can thank them 🙂 Web search Previous client Other, please ellaborate below Who can we thank for the referral? Thank you. Upon submission, your form is passed to Laura for review. If she has any questions we will be in touch with you! Please include your email below I consent to having my data collected & stored. Yes Send