Health Declaration

Please fill out the following form
in order to participate to the Raise Your Vibration event.

First Name

Last Name

Email

Do you have a hearing aid?

No

Yes

Do you have an implant in your body of any kind?

No

Yes

Are you pregnant?

No

Yes

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

No

Yes

Anything you feel we need to know prior to your experience?

No

Yes

If you answered yes to any question, please elaborate

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

I understand that any deposit paid is non-refundable.

Thanks for submitting!

Cristina Patel

Advanced Theta Healing® Practitioner & Instructor| Certified Access Bars® Practitioner | Qualified Sound Therapist

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