Date of Birth
* Date of Birth
If you had a magic wand, what is one thing you wish you can change about your body, mindset, health, etc?
If "Other," please explain:
What do you think are the causes (e.g., poor diet, stress, lack of exercise, life changes, stress, etc) of your symptoms?
What have you tried in the past (doctors, diets, physical therapists, etc) to help you manage your symptoms? If so, what are some that are particularly effective or ineffective?
Have you had any surgeries? If so, explain the area of surgeries and how long ago they took place.
Describe your current diet. What is your typical breakfast, lunch, dinner, snack, and beverages?
List any medications, supplements, and herbal remedies that you have taken or are currently taking.
Have you had any experiences with yoga? If you answered yes, what style(s) and how frequently?
What is your ideal vision of health and wellness for you?
How did you hear about me and what attracted you to work with me?
In consideration of allowing me to participate in any activity(ies) with Elaine Oyang Yoga Therapy, LLC (hereafter “Elaine Oyang”) and/or to receive any service(s) with Elaine Oyang, I hereby waive, release, and discharge any and all claims for damages for personal injury (including, but not limited to, injury, death, and property damage) which may incur, or which may hereafter accrue to me, which is caused by, arises out of, results from, and/or is in any way connected with or related to (1) my participation in any class, workshop, retreat, series, open house, or any other activity of any kind or nature, (2) my use or possession of any classroom, studio, changing room, premises, prop, or supplies of any kind or nature, and/or (3) my receipt of any yoga, nutrition consulting, massage, bodywork or any other services of any kind or type (hereinafter collectively referred to as “ACTIVITY AND/OR SERVICE”). This release is intended to discharge in advance Elaine Oyang and/or its joint ventures, partnerships, officers, directors, shareholders, partners, co-owners, yoga teachers, nutrition consultants, massage therapists, bodyworkers, employees, contractors, assigns, heirs, successors, agents, administrators, and representatives, past, present, and future (collectively referred to as “Released Parties”) from and against any and all liability which is caused by, arises out of, results from, and/or is in any way connected with or related to my participation in, use of, and/or receipt of any ACTIVITY AND/OR SERVICE, even though that liability may arise out of negligence or carelessness on the part of the persons and/or entities mentioned above. I intend for this release to be legally binding on myself, my heirs, executors, administrators, and assigns. Further, I understand my participation in, use of, and/or receipt of any ACTIVITY AND/OR SERVICE entails risks of personal injury (including death) or property damage. I hereby agree to assume all risks associated with my participation in, use of, and/or receipt of any ACTIVITY AND/OR SERVICE, and I release and hold harmless all of the persons and entities mentioned above who (through negligence or carelessness) might otherwise be liable to me (or to my heirs, executors, administrators, and assigns) for damages.
By typing your full name and hitting submit below, you agree to the liability and consent detailed above.
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