CK Tanning Customer Health Declaration Form

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					                               CK Tanning Health Declaration Form


First Name:………………………………………..                            Last Name:……………………………………….

Date of Birth:……………………………………..

Address:……………………………………………………………………………………………………………………………

Phone:………………………………..................                   Email:………………………………………………..

Emergency Contact Details:…………………………………………………………………………………………….



Please Highlight/Tick if you suffer from any of the following conditions.

Asthma                                                Hepititas A

Blood Clots/Philebitis                               High Blood Pressure

Dermatisis                                           HIV/Aids

Diabetes                                             Open wounds

Eczema                                               Psoriasis

Epilepsy                                             Rosacea

Heart Disease/Pacemaker/other                        Skin condition



Have you undergone any Plastic Surgery in the last 12 months?

Yes?……….. No?…………



Client Acknowledgement and Agreement.

I certify that the information I have provided is thus true and accurate to the best of my knowledge.

I hereby release and discharge CK Tanning and it’s Employees/Agents from any claims that I have or
may have in the future in connection with any treatment(s) I have received or may receive,
regardless of the results. I also hereby assume full responsibility for the payment of any/all services
provided by CK Tanning.



Your Signature:……………………………………………… Date:……………………………………..........................




                                    392 Ripple Road, Barking Essex, IG11 9RS
                                               Tel: 0208 591 441
                                         Email: sales@cktanning.co.uk

				
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