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Client Intake Form
First Name
Date of Birth
City
Phone
Last Name
Email Address
State
Preferred method of contact for scheduling
Email
Cellphone
Are you currently suffering from a medical condition, illness, or injury?
No
Yes
If you answered yes, please elaborate
Any major surgeries? If so, when?
Current exercise, movement or mindfulness routine. "None" is an absolutely acceptable answer.
Any additonal comments or concerns?
Where did you hear about Private Yoga with Allison?
Type your full name for signature
Today's Date
My initials above indicate that the information provided is truthful and confidential.
I have read Allison Le Yoga's Assumption of Risk and Release of Liability.
View Allison Le Yoga's Agreements and Policies
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