Wellness Device Consent Form

Wellness Device Consent Form
Please complete this form to provide your consent for the use of the wellness device and acknowledge your understanding of its use and associated guidelines.
Full Name
First NameLast Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Wellness Device Name/Type
Have you received and understood the instructions for using the device?
Do you have any known medical conditions that may affect your use of this device?
If yes, please describe your medical conditions.
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Signature (Please sign below to confirm your consent and understanding of the information provided.)
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