personal medical history form

Your Name (required)

Date of birth (dd/mm/yyyy) (required)

Mobile phone number

Land line number

Address

Your Email (required)

How can we help you? Please give a brief description of your main aim for your test.

How many hours per week do you currently exercise?

Your height (feet/inches)

Your weight (kg)

Do you suffer with any health problems?
(for example diabetes)
Please list (if required)

Important Information

By accepting this opportunity to attend a bike fit you declare the following to be both true and accurate:
• I am 18 years of age or older
• I discharge the Dean Taylor any liability for my actions whilst attending the Metabolic Assessment.
• I am voluntarily attending the premises of 17 Bull Plain Hertford SG14 1DX and waive my right to claim against the fitter for any injury occurred prior to, during or following my Metabolic Assessment, any injury occurring during the riding of my cycle or that incurred whilst or from receiving incidental advice.
• I assume all risks of injury to myself while participating in any Metabolic Assessment, and/or related activities.
• This agreement does not serve as a release or waiver of any Claims for any injury resulting from the willful, wanton, reckless, or intentional misconduct of the Dean Taylor, their/its officers, directors, agents, servants, or employees.
• If any portion or term of this Agreement is held or determined to be void, unenforceable or invalid, then such portion or term shall be severable from the Agreement and it shall remain in full force and effect.
• Before attending, please ensure that you are able to participate in the assessments as described to you. If you are at all unsure, please consult your Doctor prior to making this booking. If you attend and Dean Taylor does not believe you are in a suitable state of health you will be informed of this and your booking will not be fully refunded.

I accept the above agreement and declare that the information I have provided is correct

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