Practice Medical Form

Contact Details
Legal NameJennifer Emslie
EmailEmail hidden; Javascript is required.
Phone07482317366
TeamWomens Team
Date of Birth21/07/1994
Next of Kin DetailsIn the case of emergency, who is the best person to contact
NameLauren Davies
RelationFriend
Phone+44 7902 931722
Travel & Accomodation Details
Travel ArrangementCar (Share)
Medical
Medical ConditionsYes
Condition Details

IIH & PFO

Pre-existing injuriesNo
Medication(s)Yes
Medication Details

Acetazolomide

AllerigiesYes
Allerigy Details

Cinnamon, ibuprofen, latex, penicillin

CommentsAre there any other items that you believe the Coaches/Organisations should be made aware of?
Agreements
Authority reporting Approval
  • agreed
Insurance Coverage
  • agreed
Medical Release
  • agreed
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