Client Intake Form

Name(Required)

First Last

Email(Required)

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Any prior yoga experience?(Required)

If yes, please state where and for how long.

Current Age(Required)

Do you have any known menstrual anomalies (endometriosis, uterine fibroids, PCOS)? If yes, are you currently or have you been treated?

Do you have any children? If so, how many and their current age/s?

Are you currently or have you in the past received any treatement to fertility-related issues?

If yes, please briefly explain (to your comfort level) your current status and treatment facility.

How did you hear about Julie C. Yoga?(Required)

May we contact you should we require more information or to set up a consultation?(Required)

Please follow the link below to review the Assumption of Risk and Waiver of Liability Relating to COVID-19.(Required)

I acknowledge that I have read and understand the waiver associated with any and all practices with Julie C. Yoga.