入力内容保存/読込

Remote Quantum-Touch ® Healing Application Form

This page is the application form for Remote Quantum-Touch ® Healing by Mr. Takatoshi Tokuo at https://peraichi.com/landing_pages/view/qigong .
Name of the person who will receive the treatmentrequired
First Name 
Surname 
Symptoms you want to improverequired
Treatment periodrequired
Name of applicant
Please fill in only when the applicant's name is different from those who will receive the treatment.
First Name 
Surname 
Applicant's countryrequired
Applicant's email addressrequired

※When you input a mail address by mistake, I can't send mail to you.
~ Remote Quantum-Touch Application Procedure ~
① After clicking a button of confirm, please send it.
② Please confirm the automatic reply email message.
③ Please take one photo of the person who receives the treatment with a cell phone, a smartphone etc.
④ Please email the photo to me.
⑤ I will confirm the photo at my side.
⑥ I will send a bill by email. Please pay. I don't repay after payment.
⑦ I will confirm the photo and the receipt of your payment at my side.
After I confirm both the photo and payment, I will email the information about the starting date of the remote treatment to the applicant’s email address.
The treatment will start on the morning of the next day after the confirmation of the photo and payment.