Health Declaration

Please fill out the following form
in order to participate in our activity.

First name

Email

Have you been hospitalized in the last 12 months?

No

Yes

Last name

Date of Birth

Age

Are you suffering from a medical condition, illness, or injury?

No

Yes

If you answered yes to any question, please elaborate

Initials

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

Call/Text: 734.674.0922

Traditional Naturopath

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