Waiver and Health

Please fill out the following form.

First name

Last name

Date of birth

Month

Day

Year

Have you been hospitalized in the last 12 months?

Yes

Are you suffering from a medical condition, illness or injury?

Yes

If you answered yes to any of the questions above, please supply additional information.

Initials

Waiver Form

I declare that the info I’ve provided is accurate and complete. I have read the waiver and understand the terms correctly, accurately, and completely

Schedule an appointment

December 2025

Week starting Sunday, December 7

Time zone: Coordinated Universal Time (UTC)Phone call

Monday, Dec 8

10:00 AM - 11:00 AM

11:00 AM - 12:00 PM

12:00 PM - 1:00 PM

1:00 PM - 2:00 PM