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Welcome
I am so excited to offer you a free Chakra Reading! I just need a few simple details from you.
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Consent
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I will be using a quantum technology device to perform your free Chakra analysis. There are no contraindications for this technology (it is perfectly safe) and your personal information will remain 100% safe. Once your analysis is complete, and your report has been emailed to you, I will delete your personal information from the device and also delete this form. I absolutely assure you there is no trickery here. You will not end up on a mailing list you never subscribed to. I will never share your information with any one. That is my pinky promise to you! If you are cool with all of the above, please select 'Agree' below. If you do not consent simply click 'Don't Agree' and exit the form.
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Full Name (first and last)
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Email Address
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Please provide your email address so that I can send you your free chakra report
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Date of Birth
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5
Photo
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Please provide a recent photograph of yourself (headshot with only you in it). Without a clear photo, I cannot perform the Chakra analysis.
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