CHILD SUPPLEMENT HEALTH QUESTIONNAIRE

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CHILD HEALTH QUESTIONNAIRE
Please fill out on behalf of your child prior to purchasing any and all supplements.

Child Supplement Health Questionnaire

Please fill out a health questionnaire and release form for each individual child who will be consuming our supplements. We advise each parent and child to seek medical counsel from his or her pediatrician 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

Child Name: *

First

Last

Parent Name: *

First

Last

Parent Email: *

Parent Phone Number: *

Child Age: *

Supplements of Interest (may choose more than one): *

Children's Multi-Vitamin Children's Vitamin D3 Children's Omega Children's Probiotic Children's Nutrition Powder Baby Probiotic Baby D3 Other

Please list any medications and/or supplements your child currently takes or has taken within the last year: *

Please list if your child has had or currently has any preexisting health conditions: *

Please list any allergies, sensitivities or intolerances to foods and/or medications your child has: *

Anything else we should know? *

Please select how you would like to be communicated with on behalf of your child: *

Text Email Phone

By submitting this form, I certify that all of the information provided is true and accurate. I consent that I have read all information regarding each supplement being purchased, including ingredients, labels, warnings, allergens, dosages, age/height/weight requirements, and release CATE AND ILA, LLC from any harm that may ensue as a result of my child consuming the supplements purchased on this site. *

I AGREE

Submit

@thesouthernishmama

HOME
SLIMDOWN SHOP
SUPPLEMENT SHOP
HEALTH QUESTIONNAIRES
TESTIMONIALS
ABOUT
- ABOUT >
  - MEET THE FOUNDERS
  - CONTACT

​CHILD HEALTH QUESTIONNAIRE​Please fill out on behalf of your child prior to purchasing any and all supplements.

Child Supplement Health Questionnaire

CHILD HEALTH QUESTIONNAIRE
Please fill out on behalf of your child prior to purchasing any and all supplements.