PERSONAL INFORMATION FORM

Subscribers must be 18 years of age or older Name: _________________________________ Address:___________________________________________________________ City: _________________ State/Province: _______ Zip/Postal Code: _______________________ Email: ________________________________ Telephone: (____) ______- ________ ( home ) , (____) _____-_____(bus) <<Infomation for Lotus Medical Astrology Charts>> Date of Birth (day)____________(month)___________(year)____________ Time of Birth: _______ am/pm Daylight savings time yes____ no____ Place of Birth: ___________________________________ *** A Partial chart can be done with time of birth Brief description of health weakness(es): __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________