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Health declaration
Please fill out the following form.
First name
Last name
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
If you answered yes to any of the questions above, please supply additional information.
Initials
*
I declare that the info I’ve provided is accurate and complete.
*
Submit
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