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YogaBirth classes with Becky Richards
All information on this form is confidential and will not be shared without your consent.
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Name
*
Your answer
Email
*
Your answer
Mobile no.
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Your answer
Address
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Your answer
Due date
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MM
/
DD
/
YYYY
Your date of birth
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MM
/
DD
/
YYYY
1st/2nd/3rd baby?
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Choose
First
Second
Third
More?
Planned place of birth?
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Your answer
Are you happy with your planned place of birth?
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Yes
No
Maybe
Do you have any health problems at the moment?
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Back-ache?
Varicose veins?
High blood pressure?
Breathlessness?
Low blood pressure?
Pelvic pain?
Neck pain?
Piles
Heartburn
Depression
Other?
Required
Do you have any health problems with this pregnancy? Please give details
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Your answer
Are you happy for me to use your contact details to send you information about classes?
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Yes
No
Are you happy for me to add you to the YogaBirth class WhatsApp group?
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Yes
No
Thank you for filling in this form. Is there anything else you would like me to know before you start YogaBirth classes with me? I hope you join in with the chat at the end of classes - you can learn so much from other mums-to-be!
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