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Astrological Birth Chart Request Form


Please complete this form in its entirety as all information is relevant to creating your astrological birth chart.
Astrological Info- The astrological  information  allows me to create a birth or natal chart which is the lens thru which I enter every assessment or reading.







    *** Please provide an EXACT time of birth (birth certificate / baby book) and include am or pm please.


    *** Please provide an EXACT place of birth (birth certificate) and be sure to include County if known.






    (This information is invaluable to me for my marketing, thank you!!)


    By Checking This Box I Agree To The Following Release


    Grant For consideration which I acknowledge, I irrevocably grant to Elizabeth Thorson, RN - The Medical Intuitive (“Company”) and Company’s 
assigns, licensees, and successors the right to use my image and name in all forms and media including composite or modified representations for all purposes, including advertising, trade, or any commercial purpose throughout the world and in perpetuity. I waive the right to inspect or approve versions of my image used for publication or the written copy that may be used in connection with the images.

    Release I release Company and Company’s assigns, licensees, and successors from any claims that may arise regarding the use of my image, including any claims of defamation, invasion of privacy, or infringement of moral rights, rights of publicity, or copyright. Company is permitted, although not obligated, to include my name as a credit in connection with the image.

    Company is not obligated to utilize any of the rights granted in this Agreement.

    I have read and understood this agreement and I am over the age of 18. This Agreement expresses the complete understanding of the parties.


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