New user - WellnessLiving Systems

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First name

Last name

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Work phone

Date of birth

Gender

Address

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Referred by

Please list any condition that may affect your work with Dancing Hammock Pilates and Movement

None

Have you ever had surgery? If yes, please list below

Are you taking "blood thinners"?

Please list emergency contact name and phone number below

What is the focus of your wellness goals?

Are you pregnant or nursing?

Do you use alcohol?

Do you smoke?

If no to the last question, will you consult your physician prior to increasing your physical activity?

Physician release form/doctors note requested on

Signature: I certify that the above statements are true and correct.

Heart condition

Yes

Tick to be added to our mailing list for class updates and workshops

Have you practiced yoga before?

Do you have any limitations/injuries that may affect your practice? If so please state them below

Vaccine