Yoga Consultation Form - Home Holistics
It is important that your teacher has a full understanding of any pre-existing medical
conditions, injuries or recent surgery. For this reason, the questions on this form should be
answered thoroughly. You should not knowingly omit any information that may affect your
health or safety during your yoga practice.
Sign in to Google to save your progress. Learn more
Email *
Personal Details: Any information provided on this form will be treated as confidential.
Name *
Address including postcode
Telephone
Date of birth
MM
/
DD
/
YYYY
Would you like to join our mailing list?
Clear selection
Occupation
How did you hear about us?
Have you practised yoga before?
Clear selection
If yes, what experience do you have?
What do you hope to gain from practising yoga?
Emergency Contact: Who should we call in the event of an emergency?
Contact name
Relationship
Mobile number
General Health: Do you have any medical conditions? Please provide details.
Arthritis / Osteoporosis / High BP / Low BP / Epilepsy / Pregnancy / Recent surgery/ Other:
Physical injuries / Disabilities / Ailments: Are there any areas of concern with your body?
RELEASE & WAIVER OF LIABILITY: Please read carefully
The practice of Yoga involves physical activity (Asana), breathing exercises (Pranayama), and meditation. As with all physical activity, the risk of injury, even serious or disabling is always present and cannot be entirely eliminated. During class, the Teacher will provide verbal cues inviting you to move and breathe in a particular way, these cues are guidelines only. You should always work to your own ability. It is your responsibility to consult your GP before beginning a yoga practice, and seek medical consent where necessary. It is also your responsibility to notify the Teacher of any injury or ailment (recent or ongoing) prior to every class. Yoga may at times be challenging, but should never be painful. If at any time you believe something is unsafe for you, or that you are unable to participate due to physical injury or a medical condition, you should stop what you are doing and notify the Teacher immediately. By signing your name below, you confirm that you acknowledge and agree to the terms contained in the above waiver of liability statement.You are aware of (and assume) the risks and hazards of participating in Yoga classes, and agree to assume full responsibility for any injuries and/ or damages, which you may incur as a result of your voluntary participation. *
Required
GENERAL DATA PROTECTION REGULATION (GDPR) POLICY
When you make contact, seeking an appointment or general information (via telephone, or
email) your details may be stored electronically for a short period of time while your enquiry
is being handled.

We will not keep or store your personal details unless we are legally required to do so (if you
become a client/ customer).

We will not use your data to advertise products or services, and your details will never
knowingly be passed onto a third party.

If you would like more information on how your data is stored or, you would like your
personal details deleted, then please contact Angela Kimberley.
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy