Questionnaire Order Form

Personal Gemstone Questionnaire Order Form

Temporarily we are in the process of getting this questionaire secured. You can still fill out the questionaire and email it, but please do not put your credit card information on it. Phone, Fax or Mail your information to us. Thank you.

Phone: Call 562-402-3537

E-mail: rachel@sacredgems.com

Fax: 562-402-3269

Mail: Mail orders and payments to:
Sacred Gems, 11432 South St. #127 Cerritos, CA 9070
Attn: Rachel E. Hart

Please specifiy which you would like to order:

$54.00 Personal Gemstone determination
This is a 2 page print out of the knowledge of your gemstones and some extra comments.)

$108.00 In-depth Consultation with Rachel E. Hart
This is a 45-60 minute conversation with Rachel which will cover the knowledge of your Personal Gemstones, extra comments plus the knowledge of your soul, what you have come to master, your past lives, gifts from God, your challenges and assests and what balances them, your foundation, your strength, your projection, what opens your heart, your destiny and your best 3 days of the week to initate things on, the two days of the week not to intiate things. Plus what this year is about for you and the next 3 months. You will receive a 4-5 page printout and a time will be set where you will call Rachel for the Phone Consultation.

Please answer these questions:

Do you like to travel?	Yes No
Are you creative?	Yes No
Do you have a tendency to be emotional?	Yes No
Are you intuitive?	Yes No
Do you have problems with your digestion?	Yes No
Do you like to write?	Yes No
Are you good at communicating?	Yes No
Are you good at commerce and business?	Yes No
Is your love life wanting?	Yes No
Have you had a rough time of it romantically?	Yes No
Do you appreciate the arts?	Yes No
Do you do well in a conflict?	Yes No
Do you find you need more physical strength?	Yes No
Do you like to learn things?	Yes No
Do you feel you are prosperous?	Yes No
Do things constantly not work out financially?	Yes No
Do you like to cook?	Yes No
Do you feel restriction in your life?	Yes No
Have you had one conflict after another?	Yes No
Have things gone smoothly for you?	Yes No

What are your main concerns?

What benefits would you like to receive from wearing your personal gemstone?

Do you want to hear from us via:

Email Fax Postal Mail

Your Name
Birth Date
Place of Birth
Address
City
State
Zip
E-mail
Phone #
Fax #

Method of payment: (Please only US Currency)

Money Order
Check
Visa
Mastercard

Currently un-secure, please no credit card info at this time!

MC or VISA #
Exp. date
Name on card
Signature
Please enter the mailing address for the Credit Card:
Street Address
City
State
Zip

If this is a 108.00 consultation: Best time to call and reach you to set up an appointment

What is the time difference

How did you hear about us?

Thank you and many Blessings.

If you have any questions, please contact us at 562-402-3537

Send your comments to rachel@sacredgems.com

11432 South St. #127 Cerritos, CA 90703

Ph. 562-402-3537 Fax 562-402-3269