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Health Declaration

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

First name

Last name

Email

Date of Birth

Have you been hospitalized in the last 12 months?

No

Yes

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!

Emergency Contact Form

YOUR OWN DETAILS:

First name

Last name

Email

Phone

Address

YOUR EMERGENCY CONTACT DETAILS:

Contact First Name

Contact Last Name

This contact is my

Contact Phone Number

Contact Email

Thanks for submitting!
We’ll contact this person only in case of emergency.

HIPPA COMPLIANCE FORM

HEALING SENSATION INC

healingsensation.usa@gmail.com

©2023 by Healing Sensation.

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