Name

First Name

Last Name

Email Address

Phone

The country code for the US is 01.

Country

(###)

###

####

Illness/Disease's Medical Name

Brief History of Treatment

In less than 300 words, write out the main details of when you got the problem, and it's treatment.

Brief Testimony

In less than 300 words, write out what God did and how he did it.

Medical Records

If selected, we will need to collect your medical records. Are you willing to sign a form that will allow us to do so?

Yes

Film

If you are selected, are you willing to be filmed?

Yes

Doctors

If selected, we will need to talk with your doctors. Are you willing to sign a form that will allow us to do so?

Yes

Testimony Form