Confidential Health Form
Please complete this form to attend Iyengar Yoga classes at Zagyoga Iyengar Studio
Email address *
Name *
Your answer
Mobile or landline *
Your answer
Previous Yoga experience if you are not a regular student at Zagyoga Iyengar Studio *
Your answer
Date of birth *
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Please tick any that apply
Please add explanation and give relevant information regarding any of the above ticked boxes.
Your answer
Please list all medications
Your answer
Have you had any surgery in the last year *
Please specify if the previous answer is Yes
Your answer
Date of surgery
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DD
Name and Phone Number of Emergency Contact *
Your answer
I confirm that the above information is current and accurate. I consent to Zagyoga Iyengar Studio holding the above information for the purpose of maintaining a database and to help take into consideration any health issue for my safe practice of the yoga asanas and prananyamas. This information could also be shared with emergency services in the case of an emergency. I understand that this information will be processed in a manner that ensures appropriate security of my personal data, and this information will not be shared with a third party (other than emergency services). I understand that I can withdraw my consent at any time by contacting Zagyoga Iyengar Studio and my personal data would be erased and destroyed without delay. Once I cease to be a student of Zagyoga Iyengar Studio, I understand that my personal data will be erased/destroyed when requested. *
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