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Health Declaration
Please fill out the following health declaration form at time of booking in order to participate in your foot soak.
First Name
Last Name
Email
Phone
Birthday
Do you have have allergies to oils, herbs or fragrances?
*
No
Yes
Street Address
City
State
Postal / Zip code
I have Diabetes
I experience stress on a regualr basis
I experience frequent headaches
I suffer with inflammation
I have High Blood Pressure
I have a contagious disease
I have a cardiac and/or circulatory problem
I have numbness and stabbing pain
I have open sores
I suffer from seasonal allergies
Medications
I am pregnant
Disclaimer
Date
Initials
I confirm that the information given in this form is true
I have read and acknowledge Soothe The Soles/Vitality Ginger policies
I agree to the terms & conditions
Submit
Thanks for submitting!
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