Health Booking Form | Echo Yoga & Sound

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HEALTH BOOKING FORM | COMPLETE BEFORE BOOKING
NEW CUSTOMERS

NEW CUSTOMER HEALTH FORM

First name

Last name

Date Of Birth

GP, NAME & ADDRESS

Are You Takign Any Medication?

Please give details of recent and relevant medical treatment, operations or family history

Do you have Epilepsy?

Please list any injuries.

Are you pregnant or trying to be pregnant?

please tick if applies to you:

Deep Vein Thrombosis

Wounds/Healing

Acute inflammation/tumours

Recent surgery

Eczema

Skin Disorders

Pacemaker/heart contiditions

Shunt

Stent

Whiplash in the last 3 days

None Of The Above

I confirm that I've given is correct

Date signed

Your Signature

please share what you'd like to focus on:

Better Sleep

Reduce Stress

Create More Joy

Improve Health

Pain Reduction

Spiritual Connection

Improve Diet/Weight

Healing From Trauma

Relax

Improve Fitness

How are you in general, please note energy levels, emotional state or physical ailments.

What is your overal intention for your sound healing / yoga class?

I understand that I am responsible for my own health and safety when attending a practice with Josephine at Echo Yoga and Sound, I have disclosed all relevant information to Josephine before attending

Date signed

Your Signature

Thanks for submitting!

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Contact

Gift Cards

Echo Yoga & Sound

Based In West Worthing

BN11

West Sussex

Email:

Josephine@echoyogaandsound.com

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ECHO YOGA & SOUND

HEALTH BOOKING FORM | COMPLETE BEFORE BOOKING NEW CUSTOMERS

NEW CUSTOMER HEALTH FORM

HEALTH BOOKING FORM | COMPLETE BEFORE BOOKING
NEW CUSTOMERS