Free Evaluation

Fill out this form to receive a free Energetic Evaluation. (This is a $450 value).

Note:
In order to receive your free evaluation please be sure to take the time to read and fill out the form completely.

  • Please be sure that you read and understand what is it you are getting. Energetic Evaluation Charts 
  • Check all the statements below
  • Use one application per person, home or pet.
  • Not completing the form will delay your starting date.
  • All Fields Marked With An * Are Required
QPRS & EVALUATION ARE NOT a Medical Treatment! This program does not provide subscribers with any form of Therapy, Counseling, Medical Treatment or Diagnosis. If you think you have a medical problem, please see your doctor or dial 911. The Quantum Prayer and Resonance System has no recognized value, beyond that which the individual participants assign to it. The QPRS is a spiritual technology using advanced mathematics, fractals and prayers.*

I freely choose to participate in the Quantum Prayer and Resonance System for energetic balancing. I understand that the technology used in this program is both experimental and experiential, and that the program is currently in its testing stages.*

I know and understand that joining the Quantum Prayer and Resonance System is neither a replacement of, nor a substitute for an actual medical diagnosis, prescription or treatment. I also understand that the program dose not offer any type of counseling and therapy whatsoever. In addition, I understand that the QPRS and the Life vitality index rely on subtle energy measurements of response from the body stimuli. I further understand that this method/device has not been recognized scientifically and has no proven medical value or properties other than as it effects etheric and spiritual matters.*

I understand that the frequencies of well-being, abundance and happiness offered by the Quantum Prayer and Resonance System are accessed by me through the agency of my own Higher Self. In accordance with that understanding, I herby direct my Higher Self to connect with those frequencies that will be for the greatest good of my own health.*

Applicant Information:

Relationship to Applicant:*

App. Full Name:*

Applicant Specie:*

Applicant Sex:*

Home Phone:*

Cell Phone:

Email Address:

Birth Information:

Date of Birth: Mo/Da/Year*

City of Birth:*

State / Province:*

Country:*

On Medication /Remedy?  Yes No

Smoking?  Yes No

# Organs Removed:*

Currently In Hospital? Yes No

Mailing Address:

Address:*

City:*

State/Province:*

Zip:*

Country:*

Physical Address (If Different)

Address:

City:

State/Province:

Zip:

Country:

I declare and avow, under the laws of the United States and the state of California and the state and country of my residence, that I have read, understood and agree that all my statements on this application are true and correct. *