Medical consent form-Elite Spa

First Name

Last Name

Address

Date of birth dd/mm/yyyy

Email

Phone Number

Have you ever or are you currently experiencing any of the following ?

If yes to any of the above please give details

Are you currently undertaking any other medical supervision that we need to be aware of?

Yes

No

In case of emergency who can we contact?

Please specify anything else we should know about:

I understand that it is my responsibility to disclose to Elite Spa all medical information relating to me and that the above information is correct. I understand that Elite Spa does not diagnose illness or injuries, or prescribe medications.

Your Signature

*

Date