The Redemption Ministries Church Of Christ

Prayer register

Jesus

Card number?*

Name?*

Email?*

Create password for credential protection*

Gender?*

Age?*

Nationality?*

Place of residence?*

Profession?*

Phone number?*

Next of kin name and his/her phone number?*

Have you been on prayer line before if "yes", when?*

Please state the nature of problem(s) and all the symptoms you are experiencing. Please specify in detail*

How long have you been experiencing this/these problem (s)?*

List all medication taken /taking due to this/these problem (s)*

Have you been hospitalised due to this problem? Yes/No, If so specify when?*

Are you using any form of medical device, brace, walking stick, crutch or wheel chair to support your medical condition? (please specify)*

What are you unable to do on your own or at all as result of this sickness?*

Any surgery done or therapy as a result of the problem/condition?*

Any swollen part of body / open wound? Please specify location*

What kind of dreams do you experience?*

Please write other prayer request in the box below*

What was the feedback given to you at the hospital concerning this condition?*