VR Questionnaire and Approval Form
Required by all VR Customers
Email address *
Email Confirmation *
Your answer
First Name *
Your answer
Last Name *
Your answer
Gender *
Required
Age *
Required
Date of Birth *
MM
/
DD
/
YYYY
Address *
Your answer
Phone *
Your answer
How did you hear about us?
Name of Referral
Your answer
Other
Your answer
Guardian's Name (If Applicable)
Your answer
Guardian's Relationship to Customer (If Applicable)
Your answer
Have you had a recent concussion or head injury? *
Have you had any recent blurred vision or dizziness? *
Have you ever experienced a seizure or currently taking seizure preventive medicines? *
Have you played a professional VR system (excluding mobile devices)? *
What level do you consider yourself in VR *
If Customer is a minor or under 18 years of age, parent/guardian signature is required (Check box if a minor)
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