Information, Medical Questionnaire, Safety Instructions and Waiver of Liability
First Name *
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Last Name *
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Email Address *
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Date of Birth (MM/DD/YY) *
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Height (eg 5' 9") & Weight (eg 165 lbs) *
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Street Address, City, State, Zip *
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Emergency Contact Name & Number
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Relation to You
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Primary Care Physician Name & Phone Number
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How did you hear about Defy? *
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