Yoga Therapy Clinic
Important Contact Information
Indicates required field
Date of Birth
Do you have any injuries, illnesses or conditions?
Yes (please give details)
No (go to next field)
If "Yes" please give details
Auto Immune condition
Nervous system disorder
Other (please give details)
If "other" please provide more details
What would you like to get out of your chosen therapy session?
Build Core Strength
Improve Balance & Calmness
Come off medication
Alternative lifestyle advise
All of the above
Other (Please give details)
If 'other" please provide more details
Do you have any Yoga experience?
If "Yes" please indicate how many years?
How did you hear about us?
PAYMENT DETAILS: (Workshop via direct credit only please).
EFTPOS/Cash: At the centre
Direct Credit: Bank details on side panel
Voucher: Please insert your code below.
Account name: DASYAM LTD.
Account number: 031527 0036944 000.
Reference: Name and Workshop details
I understand there is risk of injury associated with participating in any physical exercise and I certify that I am in good physical condition and have no known disabilities that might otherwise be detrimental to my health and wellbeing, other than the ones stated on this form. I will stop any exercise if it is causing me discomfort or pain. I will take full responsibility for any injuries that might be sustained during the class.
I also understand that some classes workshops are contraindicated for certain ailments and conditions and confirm that all illnesses and conditions have been disclosed on this form so that I can be advised appropriately. Yoga Therapy Centre reserves the right to recommend the appropriate workshops for your condition based on the information provided.
Workshop cancellation policy:
Full refund, three weeks before event
50% refund, two weeks before event
No refunds thereafter, however can transfer to friend or family members for the same event
Appointment cancellation policy:
Three days notice is required for cancellation of an appointment. If cancellation is within 48 hours, 50 percent payment is required. Any appointment cancelled within 24 hours, full payment is required. Unless otherwise agreed.
Yes I Agree with the declaration and terms and conditions of this agreement
Please keep me informed!
Yes, I would like to receive updates and newsletters via email
No thank you
If you have love and care,
you will do what is needed
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Yoga Therapy Centre