This is a form that when submitted shows that you have read and agreed to The Perfect Rose "Terms of Use" or "Terms of Conditions" of service. If working with Rose at a distance this form must be filled before work is done.

Today's Date
01020304050607080910111213141516171819202122232425262728293031 JanFebMarAprMayJunJulAugSepOctNovDec 20212022

Full Name Here

Phone Number Required (Preferably Cell)

Your Email Address

Please print YES and Your Full Name in the field if you have read and agree to The Perfect Rose "Terms of Use" or also stated "Terms of Conditions"

Please check the service you have requested from The Perfect Rose (If in doubt check Combination of All Services)
Psychic or Angel Reading Energy Healing Combination of All Services Past Life Regression Quantum Healing Hypnosis Class or Workshop

Please check the areas that may require special attention from Rose for YOU
I prefer to stay within in my time request but prefer not to be checking the time
I am willing to assist in keeping track of time
I am willing to go over agreed time if I like where the session is going
I am working within a budget and I would like to stay within the time of my request for service
I am open to whatever happens

Enter the numbers from the image: