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Tanja London
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GOALS - MEDICAL HISTORY - CONSENT - POLICIES
If you have any questions please email t.london@me.com
Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Birth
*
Email
*
Phone
*
(###)
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GOALS and WISHES
What are you looking to learn in our time together?
What are your overall goals for your wellbeing and fitness?
HABITS AND CONDITIONS
What's your occupation?
Are you currently pregnant or did you give birth before?
Do you have any current or old injuries?
Please, list previous surgeries.
Do you have any allergies?
Please, list any medication you are currently taking.
Do you have or have you ever been treated for any of the following?
Heart Disease
yes
no
Asthma or other respiratory ailment?
yes
no
High Blood Pressure
yes
no
Stroke
yes
no
miscarriage
yes
no
Osteoporosis
yes
no
Kidney Disease
yes
no
Diabetes
yes
no
Low Blood Pressure
yes
no
Vascular Disorders
yes
no
Depression
yes
no
Arthritis
Rheumatoid
Osteo
no
Do you have any other old or current conditions or challenges? Allergies etc.
EMERGENCY CONTACT
Name
*
Emergency Contact
First Name
Last Name
Phone
*
(###)
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EMERGENCY HOSPITAL
*
POLICIES AND AGREEMENT
PLEASE, CHECK ALL THE BOXES!
I understand that it is important to BOOK AND CANCEL a minimum of 24h before. Sessions are otherwise not held or not refunded. In general, the sessions are not transferable and each package purchased has a specific expiry date. I understand that different studios have different policies and will adhere to their safety and general policies as well as COVID protocols. I understand that if I am later than 10 minutes to a group class that I cannot take part as for my owns health's sake. If I am late for a private session I understand that the instructor is not obliged to make up for that time.
*
I have read and agree to the above policies.
I will book a minimum of 24h via email or text - t.london@me.com or (603) 244-9439.
I will cancel a minimum of 24h via text message - (603) 244-9439.
I consent that the above information is correct and understand that it will remain confidential. Should there be any change in my condition or medication, I shall inform Tanja London accordingly and prior to class. I understand that if I have not participated in an exercise program for some time or have any underlying condition, I should consult my medical practitioners before I begin. I understand that exercise may cause injury and accept the risk and responsibility be it in the studio or online. I will inform Tanja London and stop immediately should I feel dizziness, nauseousness, pain or any feeling that may suggest any exercise is problematic at that time. In the unlikely event of me becoming unconscious, I give permission for Tanja London to arrange medical treatment for me at the listed hospital. I agree not to attend class while having COVID 19 symptoms or am under the influence of recreational drugs or alcohol.
*
I consent.
I have read and accept the conditions of this agreement.
MORE INFORMATION
Would you like to be on my mailing list?
*
YES
NO
Thank you!
