Skip to content
Online Classes
Become a Online Member
Bliss Members Login
Meet your Instructor
Classes
Overview
Yoga Group Classes
Specialised Classes
TRE
Chair Yoga
Yin / Restorative Yoga
Sound Healing
Private & Semi Private Classes
Meet your Instructor
Yoga Shop
All products
Yoga & Wellness Products
Ebooks
Meditation Bundles
Yoga Mats For Hire
Upcoming Events
Events & Workshops
Retreats
Contact
Online Classes
Become a Online Member
Bliss Members Login
Meet your Instructor
Classes
Overview
Yoga Group Classes
Specialised Classes
TRE
Chair Yoga
Yin / Restorative Yoga
Sound Healing
Private & Semi Private Classes
Meet your Instructor
Yoga Shop
All products
Yoga & Wellness Products
Ebooks
Meditation Bundles
Yoga Mats For Hire
Upcoming Events
Events & Workshops
Retreats
Contact
R
0,00
0
Cart
Waiver Form
I consent to providing my personal and medical information and understand that this information is kept private and confidential between myself and Lynnette Gouws from Ananda Wellness. Please note that by completing this sign you will receive relevant email newsletters.
Yes
Name & Suname
Contact Number
Email
Date of Birth
Physical Address
Gender
Female
Male
Emergency Name and Contact
Medical Practitioner Name and contact details
Do you have any of these conditions I should be aware of:
Asthma
Heart/Circulatory Problems
Dizzy Spells/Fainting
Anxiety
High Blood Pressure
Low Blood Pressure
Diabetes
Epilepsy/Seizures
Pregnant
None of the above
Other:
If select other above:
Please specify and explain any conditions marked above or any other conditions you may have and include if you are receiving treatment from your Medical Practitioner:
If Pregnant was selected above, Please give your Trimester details and anything specific I should be aware of
Do you have Neck / Back or Spine Injuries currently or from the past
Yes
No
Do you have any joint injury (ankle, knee, hip, shoulder, elbow)
Yes
No
Do you have any muscular injury
Yes
No
Any other medical condition, injury or disability or recent surgery?
I confirm that all personal and medical information provided in this form is true and correct and should there be any changes it is my responsibility to inform Lynnette Gouws from Ananda Wellness via email immediately.
Yes
I consent to Lynnette Gouws from Ananda Wellness contacting my Medical Practitioner and Emergency Contact should any emergency occur during any Yoga class, workshop etc
Yes
No
Send
Please familiarize yourself with our
cancellation policy.
