Waiver Form – Ananda Wellness Yoga

Skip to content

Menu

Menu

Menu

Bliss Members Login

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

Please familiarize yourself with our cancellation policy.

Let's chat

info@anandawellnessbliss.com

Bliss Members

Bliss Members Login
Bliss Membership T's & C's

Quick Links

Classes
Upcoming Events
Online Community
Retreats
Contact Me
Privacy Policy
Cancellation & Refund Policy

Newsletter

Sign up and be the first to know about all things Ananda Wellness. We share freebies every now and again, so sign up and don’t miss out!

Instagram Youtube Facebook

Instagram Youtube Facebook

Copyright © 2023 Ananda Wellness. All rights reserved.
Designed by Minamooi.

This content is password protected. To view it please enter your password below:

Password:

JOIN ME!

Click here to reserve your space