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Health declaration
Please fill out the following form.
*
First name
*
Last name
*
Phone
*
Email
*
Date of birth
Month
Month
Day
Year
Have you been hospitalized in the last 12 months?
No
Yes
Are you suffering from a medical condition, illness or injury?
No
Yes
You have insurance or with Choose Healthy Program?
Yes
No
You have allergies or Surgery in the last 12 month?
Yes
No
If you answered yes to any of the questions above, please supply additional information.
Emergency Contact
*
I declare that the info I’ve provided is accurate and complete.
*
Initials
*
Date and time
Month
Day
Year
Time
:
Hours
Minutes
AM
Submit
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