About you — Lisa Butler Yoga

Medical Disclaimer

Please tell me about you

Name

First Name

Last Name

Address

Phone number

Email

Date of birth

MM

DD

YYYY

Emergency contact name & number

Please say if you have any of the following (or contact me personally with any conditions not listed):

High/Low BP

Diabetes

Cancer

Chest Pain

Dizziness

Epilepsy

Heart Conditions

Osteoporosis

Have you had children, if so what type of birth/s (Vaginal or Caesarean):

Please list any past or present injuries and operations:

Are you on any medication?

* As far as I am aware, I have disclosed to my teacher all information regarding my health relevant to the class I am attending. Should there be any medical change I will consult my teacher. I understand that I take full responsibility for monitoring my own physical condition throughout my participation in the yoga session and that, should any unusual symptom occur, I will cease participation and inform the teacher immediately. I fully understand that the recommendations, ideas & techniques expressed & described in the classes cannot be regarded as substitutes for the advice of qualified medical practitioners.

I confirm I have read & understood the above and all the information I have given is correct, to the best of my knowledge.

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Medical Disclaimer

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