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Health declaration

Please fill out the following form.

First name

Last name

Email*

Date of birth

Day

Month

Year

Have you been hospitalized in the last 12 months?

No

Yes

Are you suffering from a medical condition, illness or injury?

No

Yes

If you answered yes to any of the questions above, please supply additional information.

Initials*

I declare that the info I’ve provided is accurate and complete.

Mocktails & Cocktails APS
Kontakt:
Hektor Pantas

hektor@mocktails-cocktails.dk

Mobil: +45 53 85 35 36

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