Waiver

Name *

First Name

Last Name

D.O.B: *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Tel No *

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###

####

Mobile *

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####

Emergency Contact Number *

(###)

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Doctor's Tel No.

(###)

###

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Acute diseases, bacterial infections or inflammatory processes? *

Yes

No

Recent operations (<2months)? *

Yes

No

Arteriosclerosis , arterial circulation problems? *

Yes

No

Stents or bypasses that have been active for less than 6 months? *

Yes

No

Untreated high blood pressure? *

Yes

No

Diabetes mellitus? *

Yes

No

Pregnancy? *

Yes

No

Electrical implants, e.g. a pacemaker? *

Yes

No

Tumours or cancer? *

Yes

No

Bleeding disorders, tendency to bleed (haemophilia)? *

Yes

No

Neurological diseases, epilepsy? *

Yes

No

Abdominal wall hernias or inguinal hernias? *

Yes

No

Neurological diseases, epilepsy? *

Yes

No

Abdominal wall hernias or inguinal hernias? *

Yes

No

Cardiac arrhythmia? *

Yes

No

Please check this box if you agree to the terms and conditions *

Yes, I agree

Signed *

First Name

Last Name

Date

MM

DD

YYYY