Health Declaration

Please fill out the following form
in order to participate in our activity.

First Name

Last Name

Date of Birth

Height:

Weight:

Have you experienced any of the following syptoms in the last 5 days: Fever, Sore Throat, Vomiting, Diarrhea?

Yes

Are you currently pregnant?

Yes

Do you have nut allergies?

Yes

Have you undergone surgery within the last 8 weeks?

Yes

Have you sustained an injury within the last 4 weeks?

Yes

Have you been diagnosed with any of the following:

Hypertension

Cancer

Diabetes

Arthritis

Neuropathy

Deep Vein Thrombosis

Aneurism

Heart Defect

Clots

None

Are you currently undergoing treatment for this/these conditions?

Yes

Are you currently experiencing any of he following skin conditions:

Rash

Sores

Psoriasis

Eczema

Sun Burn

Athletes Foot

Ringworm

None

Type any addition information you feel we should know:

I understand that my appointment may be postponed if Meraki Total Body LLC deems that approval from a medical professional is necessary before providing services.

I understand that services provided by Meraki Total Body LLC are NOT medical treatments. I will seek advice from a medical professional for all medical concerns.

I declare that the info I’ve provided is accurate & complete

I accept terms & conditions

Your Signature

Thanks for submitting!