diff --git a/src/App.js b/src/App.js
index a3d8d6a..3f3eff7 100644
--- a/src/App.js
+++ b/src/App.js
@@ -11,6 +11,7 @@ import DocumentListPage from "./Components/Document/DocumentListPage";
 import DocEditPage from "./Components/Document/DocEditPage";
 import Homepage from "./Components/Home/HomePage";
 import Dashboard from "./Components/Dashboard/Dashboard";
+import OptoutPage from "./Components/OptoutPage";
 import Container from "react-bootstrap/Container";
 import CaseListPage from "./Components/Case/CaseListPage";
 import CaseDetailsPage from "./Components/Case/CaseDetailsPage";
@@ -47,6 +48,7 @@ function App() {
         <Routes>
           <Route exact path="/" element={<Homepage />} />
           <Route exact path="/login" element={<Login />} />
+          <Route exact path="/optout" element={<OptoutPage />} />
           <Route
             path="/signup/:isUpgrade?/:currentPlan?"
             element={<SignupPage />}
diff --git a/src/Components/OptoutPage.js b/src/Components/OptoutPage.js
new file mode 100644
index 0000000..488742a
--- /dev/null
+++ b/src/Components/OptoutPage.js
@@ -0,0 +1,119 @@
+import { useState } from "react";
+import Button from "../pageElements/Button";
+import { useNavigate } from "react-router-dom";
+import Col from "react-bootstrap/Col";
+import Form from "react-bootstrap/Form";
+import Row from "react-bootstrap/Row";
+import { removalFields } from "../Constants/Fields/DemoFields";
+import { useParams } from "react-router-dom";
+import { splitEvery } from "../Utils/Array";
+import TextInput from "../pageElements/TextInput";
+import { objectMap } from "../Utils/Object";
+import { v4 as uuidv4 } from "uuid";
+import {
+  getFormDataDefaults,
+  getValidatedFormData,
+  handleFormDataChange,
+  isFormDataHasErrors,
+} from "../Utils/Form";
+import { db } from "../firebase";
+import { collection, setDoc, doc } from "firebase/firestore";
+import "../styles/demo-request-page.scss";
+
+const OptoutPage = () => {
+  const navigate = useNavigate();
+  const token = window.sessionStorage.getItem("token");
+  const [isBusy, setIsBusy] = useState();
+  const fieldsChunkSize = 2;
+  const inputFields = removalFields;
+  const [data, setData] = useState(getFormDataDefaults(inputFields));
+  const handleChangeInput = (e, name) => {
+    const newData = handleFormDataChange(e, name, data, inputFields);
+    if (newData !== null) {
+      setData(newData);
+    }
+  };
+
+  const validateData = () => {
+    const newData = getValidatedFormData(data, inputFields);
+    const hasErrors = isFormDataHasErrors(newData);
+    setData(newData);
+    return hasErrors ? null : objectMap(({ value }) => value, newData);
+  };
+
+  async function saveRequestData(dataValues) {
+    const requestDate = new Date();
+    dataValues["requestDate"] = requestDate;
+    const requestId = uuidv4();
+    try {
+      const reqRemoveRef = collection(db, "removalrequests");
+      await setDoc(doc(reqRemoveRef, requestId), dataValues);
+    } catch (error) {
+      console.log(`Error saving request data to db: ${error}`);
+    }
+  }
+
+  async function handleRequestOptOut() {
+    const dataValues = validateData();
+    if (dataValues === null) {
+      return;
+    }
+    saveRequestData(dataValues);
+    navigate("/");
+  }
+
+  return (
+    <div className="signup-super-container">
+      <div className="signup-sub-container">
+        <div className="signup-header">
+          <h2 className="signup-header-text">Opt Out of Future Emails</h2>
+          <p className="requestdemo-para">
+            Enter your email address to be removed from our mailing list
+          </p>
+        </div>
+        <Form className="demo-request-form">
+          {splitEvery(Object.keys(inputFields), fieldsChunkSize).map(
+            (names, j) => (
+              <Row key={`row${j}`} className="demo-page-row">
+                {names.map((name, i) => (
+                  <Col
+                    key={`${name}${i + fieldsChunkSize * j}`}
+                    className="mb-3"
+                  >
+                    <TextInput
+                      name={name}
+                      value={data[name].value}
+                      onChange={(e) => handleChangeInput(e, name)}
+                      error={data[name].error}
+                      message={data[name].message}
+                      label={
+                        data[name].value.length === 0
+                          ? inputFields[name].label
+                          : ""
+                      }
+                      type={inputFields[name].type}
+                      values={inputFields[name].values}
+                      disabled={isBusy}
+                    />
+                  </Col>
+                ))}
+              </Row>
+            )
+          )}
+        </Form>
+        <div className="demo-button-box">
+          <Button
+            className="primary-button demo"
+            type="button"
+            size="lg"
+            onClick={handleRequestOptOut}
+            disabled={isBusy}
+            labelText={"Request Removal"}
+          />
+        </div>
+      </div>
+    </div>
+  );
+};
+
+export default OptoutPage;
diff --git a/src/Constants/Fields/DemoFields.js b/src/Constants/Fields/DemoFields.js
index 0fc9159..50fa245 100644
--- a/src/Constants/Fields/DemoFields.js
+++ b/src/Constants/Fields/DemoFields.js
@@ -34,3 +34,7 @@ export const supportFields = {
     maxLength: 45,
   },
 };
+
+export const removalFields = {
+  email: { required: true, label: "Email", maxLength: 45, type: "email" },
+};