Health Information Form



Customer elects to provide the following responses to items A through F below, which responses are complete, true, and correct to the best knowledge and belief of the Customer, with the intent that MasterDry, LLC may rely upon such responses for all purposes.

Customer declines to provide responses to items A through F below, with the understanding that the lack of such responses may limit the ability of MasterDry, LLC to provide appropriate recommendations.



A. Does any resident or frequent invitee of the Work Site have any known allergies? (required)

If yes, list the allergies:



B. Does any resident or frequent invitee of the Work Site have any known sensitivity to chemicals? (required)

If yes, list the chemicals:



C. Does any resident or frequent invitee of the Work Site under the care of a physician? (required)

If yes, for what medical condition:



D. Does any resident or frequent invitee of the Work Site have respiratory problems? (required)



E. Does any resident or frequent invitee of the Work Site have a deficient immune system? (required)



F. List any health-related concerns that Customer has regarding the services of MasterDry, LLC:



Customer Signature:

Date: