Gem Prescription

Request Form

If you have not already done so please read a description of all of our services including this one. If anything is unclear or you have questions please contact me. Please be sure to include your email address in the appropriate space, without it we cannot contact you.

In order to protect you from credit card fraud we are recording your IP address for security purposes.

Your IP address:

I want a Gem prescription ($150):

Rush my order (add $100):

The answer will be sent to you as an email.
Your email address:

Comments: How did you hear about this site? Any comments or suggestions regarding this site or our services.


Please note that this service does not include any types of predictions other than a Gem Prescription.

Data required for Gem Prescription

If you want to have more than one chart done re-submit the form as many times as necessary with the different birth information.

First Name:
Last Name:
Initial:
Name at birth if different from above:
Sex:
 Male Female
Birth Data:
 Please note that if the time or date of birth are unknown or inaccurate then we will have to rectify the chart.
Date of Birth:
 Day Month Yr
Time of Birth:
 Hours Minutes (military time)
Source of birth time (hospital record, birth certificate, mother's memory, other)
Place of Birth:
City:
State/Province:
Country:
If born in a small village give the name of the nearest town and approximate distance:
Nearest large town:
Distance from birth place:
 in miles.



Payment Method: card type



First name:
Last name:
Initial:
Account number: (no spaces)
Expiration date: Month Year
Card Verification Number What is that?
Amount:
Billing address:
Apt #:
City:
State/Province:
Country:
Zip/Postal Code:
Telephone:
Country Code:

Check all birth data. Please read
the following carefully.

Have you included your email address as requested at the beginning of this form? We need it to contact you.

Before submitting this form please review all the information you have provided especially your birth data. We assume that the information you provide is correct. Errors or mistakes in this regard are your responsibility. If the chart has to be done again because you gave wrong data it will be done as new chart at full price. So get it right the first time.

Also please note that when you submit this form it is not automatically processed. Why is that important to you? Because that means that your card will not be automatically debited, in other words you will not be charged until after the work is done, however a pre-authorization will be done just before commencing the work to lock in the funds.

To recognise the transaction on your credit card statement the billing descriptor will be "Shyamasundara Dasa."

By checking the box I affirm that have read the terms of service and agree to be bound by them.

To authorize please type "I agree" here: