ADULT SUPPLEMENT HEALTH QUESTIONNAIRE

Adult Supplement Health Questionnaire

Please fill out a health questionnaire and release form prior to consuming our supplements. We advise you to seek medical counsel from your healthcare practitioner prior to taking any supplements. If you would like a more detailed consultation with respect to supplements, please email hello@postpartumslimdown.com.

* Indicates required field

Name: *

First

Last

Email: *

Phone Number: *

Age: *

Height: *

Are you pregnant? *

Yes No

Are you breastfeeding? *

Yes No

If applicable, please specify when you stopped breastfeeding: *

Are you on any medications? *

Yes No I'm not sure

If yes, please list: *

List of current medications and/or supplements: *

List any preexisting health conditions (i.e. anxiety, depression, breast cancer, insomnia, autoimmune, etc.): *

List any allergies, sensitivities or intolerances to foods and/or medications: *

Anything else we should know? *

Please select how you would like to be communicated with: *

Text Email Phone

WARNING: Some of these products may contain ingredients of soy, tree nuts, sardine, anchovy, mackerel. When taking the supplement(s), please follow directions and take recommended doses. We recommend keeping our supplement(s) out of child reach in-case of accidental overdose. If there is an accidental overdose of you or your child, please call a doctor or poison control center immediately. By submitting this form, I agree that any and all information provided above is accurate and true. I agree that I have thoroughly read any and all information pertinent to the supplements being purchased, including ingredients, labels, warnings, allergens, age/height/weight requirements. If agree that I do. not have any preexisting health conditions that would put me in danger as a result of taking the supplements. I agree that I have received medical consent to take such supplements from my healthcare practitioner or a Postpartum Slimdown practitioner in the event that I do have a preexisting medical conditions, am pregnant and/or nursing. I finally release CATE AND ILA, LLC from any damage or injury caused as a result from consuming the purchased supplements taken. *

I AGREE

Submit

​ADULT HEALTH QUESTIONNAIREPlease fill out prior to purchasing and consuming any and all supplements.

Adult Supplement Health Questionnaire

ADULT HEALTH QUESTIONNAIRE
Please fill out prior to purchasing and consuming any and all supplements.