Patient Profile

These healing and “dum” treatments are given absolutely free as a service for humanity in the name of Almighty Allah

Patient Profile: Please fill out all portions of the form

Patient Information form

The above information is true to the best of my knowledge. I authorize that the above information can be used for any medical or research purposes. I hereby acknowledge that the treatment I intend to receive is purely based on my own consent. I also understand that I will not hold the facility, any of the facility's affiliates, or the spiritual healer responsible for any side effects or conditions that might result in future.