Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Do any of these conditions and symptoms currently apply to you.

Respiratory problems

Heart problems

High blood pressure

Low blood pressure

Cancer

Diabetes

Mental health issues

PTSD

Arthritis

Epilepsy

Auto-immune disorder

Eye problems

Recent fracture/sprain

Recent surgery

Pelvic issues

Recent pregnancy

Currently pregnant

Recent miscarriage

Digestive issue

Menopause

Anxiety/depression

Long Covid

joint pain

Hyper-mobility

Osteoporosis

Other

Are you currently taking medication?

Yes

No

Are you currently seeking any medical attention, or receiving complimentary therapy, that I need to be aware of?

Yes

No

Do you need to be signed off by a doctor before you begin class / course / workshop?

Yes

No

Are you interested in hearing about my future yoga classes, courses and workshops

Yes

No

If at any time during the class, you feel discomfort or strain, gently come out of the posture. You may rest at any time during the class. It is important in yoga that you listen to your body, and respect its limits on any given day. I, the undersigned, understand that yoga is not a substitute for medical attention, examination, diagnosis, or treatment. I should consult a physician prior to beginning any activity program, including yoga. I recognise that it is my responsibility to notify my teacher of any serious illness or injury before every yoga class. I will not perform any postures to the extent of strain or pain. I accept that neither the instructor, is liable for any injury, or damages, to person or property, resulting from the taking of the class and I do so at my own risk. *

I agree to the terms stated above

I disagree to the terms stated above

I accept the general terms of service available to view at https://www.yogawithtiffy.com/terms-of-service *

Yes