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Health declaration

Please fill out the following form.

Date of birth
Month
Day
Year
Have you been hospitalized in the last 12 months?
No
Yes
Are you suffering from a medical condition, illness or injury?
No
Yes

Annie V   Holistic Image Consultant

'For in him we live and move and have our being.'

Acts 17:28

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Annie@AnnieVImage.com
| TEL.513.463.7330

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