Ayurveda Health Checklist Form

Health Checklist Form

Please complete the following health checklist form prior to our Yoga session with Geny Caloisi, from CheYoga and Ayurveda Wellness.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date

MonthDayYear
Date
Have you experienced any of the following symptoms in the past 14 days? (Select all that apply)

FeverCoughShortness of BreathSore ThroatLoss of Taste or SmellFatigueHeadacheMuscle or Body AchesNasal CongestionNausea or VomitingDiarrheaOther
Do you have any of the following:

High or low blood pressureInjured joint or extremityInjured spineHerniaHigh Blood pressureHeadaches/MigrainesEye problemsArthritisEpilepsyHeart ConditionAre you on Medication?Are you pregnant?
Please give any further details, include allergies, food or other.
Emergency contact
Have you experience Ayurveda consultation or treatments before? Please provide any additional comments or information.
Cancellation Policy:

Clients must email the therapist (geny@cheyoga.co.uk) to cancel.

Full refunds are given if cancellation occurs:
- More than seven days before a treatment.
- Cancellations with fewer than a week's notice are non-refundable.
- You can [purchase present vouchers, but treatments are non-transferable to other clients once booked.
Therapist Cancellation

The therapist can cancel with a full refund to the client within three days of the treatment. A new date will be offered before cancelling.
The therapist can cancel or modify the appointment due to unmanageable conditions (natural disasters, illness, pandemics, war, etc.).
RELEASE OF LIABILITY

By signing below, you agree to be legally bound by this agreement and release of liability. This is a binding legal contract between you, Geny Caloisi, the Ayurveda Consultant and Therapist, and her limited liability company, Che Yoga and Ayurveda Wellness.
Signature

Clear
Find out more about Geny Caloisi on:

Instagram: https://www.instagram.com/geny_caloisi/
Podcast:https://podcasters.spotify.com/pod/show/geny-caloisi
Youtube:https://www.youtube.com/c/CheYogaGenyCaloisi
Fb: https://www.facebook.com/cheyoga.london

Website: www.cheyoga.co.uk
Should be Empty: