Health Declaration

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

Thanks for submitting!

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