YourTime Wellness Free Taster Workshop Intake Form

Taster Session Booking Form

Please complete before your 1st session. All information is held securely and kept in the strictest confidence
Full Name:
Preferred Name:
Date Of Birth:

DayMonthYear
Date
Address

House number or name

Street Address

Town/CityCounty

Post code
Home Phone Number:
Ok to leave a message?

YesNo
Work Phone Number:
Ok to leave a message?

YesNo
Mobile Phone Number:
Ok to leave a message?

YesNo
Email Address:*
example@example.com
Preferred contact method
How Would You Describe Your Physical Fitness?
Are You On Any Medication?

YesNo
Please provide details of any medication you are presently taking
Have you ever been diagnosed with have any of the following?

A pacemaker or internal defibrillatorA Cochlea implantHearing aid(s)A joint replacement(s)High blood pressure not controlled by medicationEpilepsyYour are or maybe preganantDigestive issues, such as IBSIrregular heart beatsSevere or critical illness, such as cancer. Please list details belowPost Traumatic Stress Disorder (PTSD)Phobias. Please provide details below
Please provide further details
Emergency Contact:
Relationship To You:
Emergency Contact Number:
What Are You Expecting To Achieve From This Session?
Which date would you like to attend? Please only select one date.

Wednesday 25th February, 7.15-8.30pm (Waitlist)Friday 27th February 10-11.15am (Waitlist)Friday 27th February 12-1.15pm
Would you be willing to consider an alternaitve date?
Would you like to be added to our mailing list?*
How Did You Hear About Us?
Signed:
Dated:

DayMonthYear
Date
Should be Empty: