Healing Prayer Request Form
We are committed to praying for you until you have a testimony
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Full Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
-
Area Code
Phone Number
Check the conditions that you are seeking personal prayers for or for any members of your family:
*
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
COVID-19
Allergic Disease
Emotional disorder
Bleeding
Bone Pains
Arthritis
Blood disorder
Acute Respiratory disease
Avian Influenza
Eye diseases
Musculoskeletal conditions
Neurological diseases
Brain Injuries
Weather Related Injuries
Skin Infections
Zoonotic diseases
Other
Are you currently taking any medication?
*
Yes
No
Do you have history of the disease mentioned above in your family?
*
Yes
No
Not sure
Any other information you are willing to share or detail of your disease if you check others?
Do you have personal relationship with Jesus?
*
Yes
No
Not sure
I don't understand
If you did not pick YES above, will you like to discuss further on that question? (Note: your response to this question has nothing to do with either we are praying for you or not)
Yes
No
Prefer not to answer
Not decided
Not sure
Please verify that you are real
*
Confidentiality
The information provided will be treated with utmost confidentiality. No part will be printed or shared except on prior and express permission of the author.
Submit
Should be Empty: