Smile Application Form
Smile Application Form
Name Address
Email Occupatio n Emergency Name & No. Membership Duration Membership Type
Fem ale
3 months Senior/Studen t
6 months Corporate
12 months Other
About you Your training Weight loss Weight goals gain Your Height Your Weight Your general health (please Diabetes
indicate if any apply)
Rehab
Stress relief
Shortness of breath
Hypercholesterolaemi a
Your BMI Heart Chest pains Disease Allergies Recent childbirth Oedema Tachycardia Seizures Asthma
Palpitations Other
Details:
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