New Client Information Form

Elizabeth will review your details and contact you via email to schedule your free 20-minute phone meeting to discuss her proposed treatment plan. No cost or obligation! 

Please complete the form below

Name *
Name
Phone *
Phone
Address *
Address
Health History
Do you suffer from any of the conditions below?
Do you suffer from general aches and pains?
i.e. I feel an electric shock in my neck when I turn it to the right. My right knee feels like it's being stabbed when I bend more than 90 degrees.
I UNDERSTAND THAT THE PURPOSE OF THE MOVEMENT PROGRAMS IS TO DEVELOP AND MAINTAIN OVERALL WELLNESS, FLEXIBILITY, JOINT MOBILITY AND DECREASE STRESS. ALL SESSIONS INCLUDE WARMUP, BREATHING AND SIMPLE MOVEMENT. THE PROGRAMS INCLUDE, BUT ARE NOT LIMITED TO HATHA YOGA, GENTLE YOGA, RESTORATIVE YOGA, YIN YOGA, POWER YOGA, YOGA TUNE UP® & VARIOUS FITNESS MODALITIES. I UNDERSTAND THAT I AM TO LISTEN TO THE FEEDBACK MY BODY IS GIVING ME AND RESPONSIBLE FOR MONITORING MY OWN CONDITION & THROUGHOUT THE SESSION, SHOULD ANY PAIN OCCUR, I WOULD CEASE MY PARTICIPATION AND INFORM THE INSTRUCTOR. IN SIGNING THIS CONSENT FORM, I AFFIRM THAT I HAVE READ THIS FORM IN ITS ENTIRETY AND I UNDERSTAND THE NATURE OF THE PROGRAM. I ALSO AFFIRM THAT MY QUESTIONS REGARDING THE PROGRAM HAVE BEEN ANSWERED TO MY SATISFACTION. IN CONSIDERATION FOR BEING ALLOWED TO PARTICIPATE IN THIS EXERCISE PROGRAM, I AGREE TO ASSUME THE RISK OF SUCH EXERCISE, AND FURTHER AGREE TO HOLD HARMLESS MY CERTIFIED YOGA TEACHER, ELIZABETH WHISSELL, FROM ANY AND ALL CLAIMS, SUITS, LOSSES OR RELATED CAUSED OF ACTION FOR DAMAGES, INCLUDING, BUT NOT LIMITED TO, SUCH CLAIMS THAT MAY RESULT IN MY INJURY, ACCIDENTAL OR OTHERWISE, DURING OR ARISING IN ANY WAY FROM THE SESSIONS. 24 HOURS CANCELATION NOTICE IS REQUIRED, ANYTHING AFTER 24 HOURS WILL BE CHARGED A $50 CANCELATION FEE. NO-SHOWS WILL BE CHARGED THE FULL APPOINTMENT COST.
How did you hear about Yogarific with Elizabeth? *