Smiles for Your Service Application
"
*
" indicates required fields
Facebook
This field is for validation purposes and should be left unchanged.
Name
*
First
Last
Date of Birth
*
MM slash DD slash YYYY
What is your gender?
*
Male
Female
Phone
*
Email
Check the conditions that apply to you or to any members of your immediate relatives:
*
Asthma
Cardiac disease
Hypertension
Epilepsy
Cancer
Diabetes
Psychiatric disorder
None
Other (please list below)
Other Conditions
Check the symptoms that you're currently experiencing:
*
Chest pain
Cardiac disease
Hematological
Neurological
Gastrointestinal
Weight gain
Musculoskeletal
Respiratory
Cardiovascular
Lymphatic
Psychiatric
Genitourinary
Weight loss
None
Other (please list below)
Other Symptoms
Are you currently taking any medication?
*
Yes
No
Please list medications below
Do you have any medication allergies?
*
Yes
No
Not sure
Please list medication allergies below
Do you use or do you have history of using tobacco?
*
Yes
No
Do you use or do you have history of using illegal drugs?
*
Yes
No
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
Branch of Service
*
Years of Service
*
Consent
*
By checking this box you agree to allow Smiles for Your Service to review your information and contact you with any questions regarding your application.
