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About you
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Indicates required field
Name
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First
Last
Address
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Email
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Mobile Number
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Date of Birth
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Place of Birth
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OCCUPATION
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Marital Status
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Single
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Children
*
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One
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Health History
Current Health Concerns
*
High Blood Pressure
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Asthama
Diabetes
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Acidity
Menstrual Concerns
Nervous System Conditions
Auto Immune
Weight Concerns
Other
If ticked "Other", kindly outline your health concern
*
What are you seeking from your session or enquiry?
*
Where did you hear about us?
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Word of mouth
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Informed Consent
Please note and confirm your acceptance to YTC terms outlined below:
I agree to
*
Providing all necessary health related information to enable an appropriate yoga treatment to be prescribed
I agree to
*
Making every attempt to comply with the Yoga and Ayurveda Treatment plan
I agree to
*
Advise YTC of any Yoga or Ayurveda Treatment that I feel is contrary to my wishes
I agree to
*
Stop any exercises if it is causing me discomfort or pain
I agree to
*
Be contacted by YTC via e-amil or telephone as is required for my health concerns
I agree to
*
Take care of my body during any session and take responsibility for any injuries that might be sustained.
I agree to
*
Disclose any allergies I have to oils / herbs
I agree to
*
Honour the cancellation terms noted below
Yoga Therapy Clinic operates on the following terms:
We do not diagnose.
Nothing we do or imply should be construed as diagnosis.
We attempt to ascertain factors about your health issues.
We make no attempt to cure any “conditions”.
We do not claim, imply or suggest that any treatment will be cure any condition, nor that the purpose is to cure any condition.
The purpose is to support the body to regain health.
Prescriptions given as part of the consultation are not to be construed as treatment for any disease or disease process, but rather as supporting client towards wellbeing.
We do not attempt to interfere with medical advice in any way.
We cannot advise you on medication given to you by your GP.
Please always ask your GP for advice on your medication
Payments for 1 week before to secure your appointment.
I understand that sessions may overrun and in these instances a fee of $55 is application for each 30 minutes thereafter.
Appointment Cancellation Notice:
3 days required, any cancellation within 48 hours 50% payment applies.
Any appointment cancelled within 24 hours, full payment applies, unless otherwise agreed.
I acknowledge the terms above and agree to treatments under these terms
*
Yes
SUBMIT
HOME
About Yoga Therapy
About Ayurveda
About Me
Videos
Contact
Programmes
Inner Pharmacy Course
Weight Management
Individualised Programmes
Offerings
Yoga Therapy
Body Therapies
Skin Therapies
Wellness Talks
WORKSHOPS
Retreats
Consent Form