New Yoga Client Intake &

Health History Form

If patient is under 18 years of age, enter guardian information below.

I authorize the collection and use of the above personal information as is required for therapeutic treatment and related administrativepurpose. I understand that allmy personal information is confidential and will not be released without my signed consent.I understand that yoga is not a substitute for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions. By signing, I affirm that a licensed physician has verified my good health and physical condition to participate in yoga classes offered by Holistic View Retreats.

In addition, I will make my yoga instructor aware of any medical conditions or physical limitations before class. If I am pregnant, become pregnant or I am post-natal or post-surgical, my signature verifies that I have my physician's approval to participate. I also affirm that I alone am responsible to decide whether to practice yoga and participation is at my own risk. I hereby agree to irrevocably release and waive any claims that I have now or may have hereafter against Holistic View Retreats.