HEAL, ALIGN & TRANSFORM
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HEAL, ALIGN & TRANSFORM
Home
About
Private Yoga
Pre/Postnatal
Back Care
Blog
Gift Certificates
Testimonials
Contact/Waivers
0
Prenatal Waiver
Prenatal Waiver
Name
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Mother's Date of Birth
*
MM
DD
YYYY
Current Week of Pregnancy
*
Expected Due Date
*
MM
DD
YYYY
Number of Pregnancies (Inc Current)
Number of Vaginal Births
Number of C-Sections
Number of Miscarriages
Number of Children and Ages
Doctor/Midwife/Healthcare Provider Name and number
Anticipated Place of Birth
Have you discussed doing physical activity during your pregnancy with your health care provider?
Yes
NO
Will do it soon
Did your doctor set any parameters to your physical activity? If yes explain:
Have you done yoga before?
Yes
NO
If yes, how long?
During current pregnancy or previous, have you experienced (Check/Circle all that apply)
Bleeding from the vagina (spotting)
Absence of fetal movement after 6th month
Unexplained faintness or dizziness
Failure to gain weight after 5th month
Unexplained abdominal pain
Hypertension
Sudden swelling of ankles, hands, or face
Placenta Previa? Full or Partial?
Swelling, pain or redness in calf of one leg
Diastasis Recti
Varicose Veins/Hemorrhoids
Pre-eclampsia
Other high risk diagnosis:
Please name other physical limitations, pains, stress, ect. I should know about?
Do you have any issues, fears or phobias, associated with this pregnancy or birth in general?
How did you hear about our Prenatal Yoga?
Cancellation/Refund Policy:
I understand there are times where a student may miss a class due to a variety of reasons. Unfortunately, there are no refunds for a missed class. There are no credits for missed classes. There are no makeup classes. If you are unable to complete the session due to a pregnancy related medical reason that will persist for the remainder of your pregnancy (i.e. incompetent cervix, pregnancy hypertension, risk of preterm labor, etc.), please provide a doctor’s note with medical reason and you may be refunded the remainder of the paid session.
AGREEMENT OF RELEASE and WAVER OF LIABILITY
Please read carefully before signing As a student of this prenatal yoga class: ❖ I understand that there is a risk of injury associated with yoga as with any physical activity in pregnancy. To reduce risk of injury, consult your doctor before beginning this program. ❖ I am fully responsible for the outcome of my yoga practice and participation in this class. ❖ I understand that Lilian Yoga and Lilian Lee can not make a determination about the safety of prenatal yoga class for each individual woman and her unborn child. Only my doctor/midwife can only make such a determination. ❖ I understand that if I move with care, intelligence, safety and self-awareness, injury is unlikely. Should injury occur or complications arise, Lilian Yoga, all teachers, substitutes, employees, and affiliates are absolved of all responsibility. ❖ I understand that I should report any problems with my pregnancy to my physician/midwife. ❖ I will keep my yoga teacher informed with any changes in my pregnancy or physical health. ❖ I am having a healthy pregnancy. ❖ I am under a physician’s or midwife’s care and have his or her consent to participate in this prenatal yoga program. ❖ I will keep my yoga teacher informed with any changes in my pregnancy or physical health. I FURTHER STATE THAT I HAVE CAREFULLY READ THE FOREGOING RELEASE AND ITS CONTENTS. I FULLY AGREE WITH IT AND UNDERSTAND IT.
Printed Name
First Name
Last Name
Signature
Date
MM
DD
YYYY
Thank you! Looking forward to work with you.
