EPIC Ruqyah Center - Patient Form

Service Terms and Conditions

All service recipients must meet the requirements below :

General :
- All service requests are subject to approval.
- Each appointment is for 1 person only.
- Indivituals under 18 years of age must be accompanied by a guardian.
- Female must be in Hijab & be accompanied by a mahram.
Prerequisites:
- Submit the Client form prior to requesting appointment.
- Review and agree to service Terms, Conditions, Consent and Waivers.
Appointment:
- Clients must submit a request for a service appointment and receive confirmation.
- Cancellation permitted 72 hours prior to appointment without penalty.
- Cancellations under 72 and before 24 hours prior to appointment will incur a fee of $25.00
- Changes under 24 hours are not allowed
- No Shows will incur a fee of 100% of the service price.
- Late arrivals will result in shortened sessions.
I acknowledge EPIC Ruqyah Service is neither a healthcare provider nor is it qualified to provide any medical advice. It is important that you be examined by a medical doctor to confirm that you do not have a medical condition that can be diagnosed and treated by common medicine.*

Check this box to confirm that you have read and agree to the above Terms and Statement:

Identification
Client Name*

First NameLast Name
If filling on behalf of someone else

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Martial Status
Gender
Age*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Part A: Background
Q.A1) Why are you seeking Ruqyah?*
Q.A2) When did the condition start?
Q.A3) Have you been diagnosed by a professional doctor/ health care provider ? Are you under a medical treatment plan or taking any medication ? Please provide details.
Q.A4) Have you seen a spiritual healer / Raqi ? How was the Ruqyah done ? What was the recommendation provided post ruqyah ?
Q.A5) Have you done Self Ruqyah ? If yes, briefly describe your condition.
Q.A6) Do you wear or have amulets (taweez), charms, or have talisman at home for good luck, prosperity, protection, etc?

YESNO
Q.A7) Are you or member of your family involved with spiritual occult practices ?

YESNONOT SURE
Q.A8) Is any of your family member afflicted or diagnosed with magic or Jinn possession?

YESNONOT SURE

Part F : Material Affairs
Q.F1) Do you experience constant blockages in your affairs ?

Part G : Details
Q.G1) Describe your condition in detail (including any condition not covered in previous sections )
Q.G2) What is the frequency of the condition ?
Q.G3) What makes the condition worse or better?

CONSENT FOR RUQYAH SERVICE

Purpose of Service
Ruqyah is a spiritual practice based on recitation of Qur’an and supplications. It is offered for spiritual support and should not be understood as medical treatment. Ruqyah practitioners at EPIC Ruqyah Center are not medical professionals, and this service does not replace medical care from a licensed doctor.

What to Expect
During a Ruqyah session, the practitioner may:

Recite Qur’an and supplications
Blow air or lightly touch (with consent)
Offer general spiritual advice
Suggest use of items commonly known in Islamic tradition (e.g., certain oils, water, or herbs)
Any physical remedies (such as massage, cupping, or acupressure) are not part of this service and, if ever mentioned, are considered optional faith-based practices outside the scope of EPIC Ruqyah Center.

No Guarantee
There is no guarantee of specific results. Ruqyah is a form of spiritual help, and outcomes are in the hands of Allah.

Privacy
We respect your privacy. Information you share will be kept confidential and used only for providing Ruqyah services. We will not release your personal information to others without your permission, unless required by law.

Payment
I understand that I am responsible for payment of services received, unless other arrangements have been made in advance.

Consent
I confirm that I have read and understood this form. I consent to receive Ruqyah services for myself and/or my child(ren), knowing that this is a spiritual practice and not a substitute for medical treatment.
Signature*

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Identification

Part A: Background

Part B: Faith & Practice

Part C: Psychological (During Day/Work Time)

Psychological (During Night / Sleep Time)

Part D : Physiological

Part E : Relational & Behavior

During Night/Sleep Time

For Married - Behavior with Spouse

Part F : Material Affairs

Part G : Details

INTERNAL