IN-PERSON MODULE

Preparation Form

Please complete this preparation form before attending the in-person module.

PREPARATION FORM

In-person Module

NAME *
CONTACT IN CASE OF EMERGENCY
CURRENT STATE OF HEALTH — PLEASE SELECT WHAT'S APPLICABLE *

Please inform us about any medical condition that you may have, so in case of emergency we can inform relevant doctors about it.

PREVIOUS STATE OF HEALTH — PLEASE SELECT WHAT'S APPLICABLE *
ARE YOU TAKING CHRONIC MEDICATION? *
DID YOU TAKE CARE OF THE FOLLOWING? *
I ACKNOWLEDGE: *
BY SIGNING I ACCEPT THE TERMS AND CONDITIONS *

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