Name
Surname
Date of birth
In
State
Adress
Street
N°
Mobile
Email
To prevent your physical status, We kindly invite you to answer at the questions below:
Pregnancy status NoYes
Surgery NoYes
If yes, Which one
Allergies NoYes
If yes, which one
Cardiovascular diseases NoYes
Breathing problems NoYes
Infectious diseases NoYes
Hepatitis NoYes
I declare under my own total responsibility that the answers given are true, therefore emmeManagementGroup SrlS disclaims of any responsibilities
I AGREE pursuant to and for the purposes of the articles. 13 and 23 of the Legislative Decree. n. 196/2003, by signing this form, to the processing of personal data according to the methods and within the limits.