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Relax, Restore, Revitalize
Vim & Vigor Pain Relief Package Giveaway
Entry Form Continued...
Describe past treatments and surgery that have been undergone to address your pain issue
What has helped and what didn’t work? (Please give as many details and descriptions as you can)
Please list your current medical diagnosis and treatments
What medications are you currently taking?
Have you been told that your condition can not be fixed? (Yes or No)
Yes
No
If Yes, what was the reason? (ex. Old age, bone on bone, etc.)
Submit Giveaway Entry Form
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