CLIENT  DATA  FORM

	Last Name:			FIRST NAME:		GENDER:
	BIRTH DATE (in Year-Month-Day format):
	BIRTH TIME (in Hour:Minute:Second 24 hrs format):
	ACCURACY OF TIME:
	BIRTH PLACE (as City/Town and Country/State):
	Education:			Occupation:
	Physical Features:	Height:		Weight:		Blood Group:
			Eye Color:	Hair Color:
			Hair Length:		Facial Hair:
			Build:		Ethnicity:		Disability:
	Habits:	Smoking:		Drinking:
	Religion:				Religious Practice:
	Marital Status:			Sexual Orientation:
	Date of marriage:			Date of Divorce:
	Biological Children:	Birth Date:		Gender:
	Spouse:	Birth Date:		Gender:
	Accidents:	Type:			Date:
	Operations:	Type:			Date:
	Hospitalization:	Date of Entry:		Cause:
			Date of Release:
	Employment:	Date of Entry:		Type:
			Date of Termination:
	Hobbies/Interests:

	SELECTED PROGRAM:	SELECTED DURATION:	REPORT TYPE:

	PRESENT PROBLEM:

	Additional Notes:

	FAX NUMBER:		Phone Number:		Date of Entry:
	POSTAL ADDRESS:

	A hardcopy of this form is intended to be faxed or mailed by those who cannot access to Internet,
	after being filled out by the client. Please do not change the format or the content of the form, and
	fill the appropriate blank fields only.
	Entering incorrect information effects the astrological profile used in analysis, and causes erroneous
	results. Therefore, please do not give false or estimated information. In case of uncertainty, you may
	leave the field blank.
	Field definitions indicated with capital letters are essential, and must be filled out. Either a fax number
	or a postal address should be given.
	A name is required only for archiving purposes. You may use a nickname if you prefer, and it will not
	effect the results.
	Client forms are evaluated after the appropriate payment. Selected program field entries determine
	the type of report, and conveyance.
	For consultation meetings, please arrange an appointment by phone, in advance.
	Fax:  0(0-90)-216-4859578
	Phone:  0(0-90)-216-3634974
	Post:  P.O.Box 9 - Kiziltoprak - 34725 - Istanbul - Turkey 
	Copyright (c) 2003-2007 Haluk Akcam. All rights reserved.