New Client Waiver

Serendia Wellness, Jessica Barker

Kingcup Drive, Bisley, Surrey GU24 9HH

Phone: 07707 816 606

Email: Jessica@serendiawellness.com
Name*

First NameLast Name
Date of Birth

DayMonthYear
Date
Email*
example@example.com
Phone Number*
Address*

Street Address

Street Address Line 2

CityCounty

Postal / Zip Code
Medical Declaration: Are you currently experiencing any of the following?*

Asthma / Other breathing problemsMuscular/Joint InjuryRecent operationsHigh blood pressureLow blood pressureSevere uncontrolled hypertensionSevere/critical diseases or infections - impairing ability to breatheHeart ConditionIrregular heart beatPacemaker or similarOrgan failure or late-stage terminal illnessEpilepsy or history of seizuresDiabetesSevere mental health conditionPTSDAuto-immune diseaseTinnitusPregnancy **If so, it is recommended that you seek a prenatal yoga specialist.Recent surgeryNone of the above or anything to my knowledge to be discussed
Please give further detail here regarding medical info if required
Are you pregnant? If so please inform us of number of weeks below. *Please note, it is recommended to seek a prenatal Yoga specialist as these sessions may not be suitable. Sound baths are generally safe and deeply relaxing, but they may not be suitable for those who are pregnant (particularly in the first trimester)

YesNo
A gentle reminder:

While sound and breathwork practices are generally safe and deeply supportive, there are a few instances where extra care or medical advice is recommended.

Please let me know on this form AND in person if any of the following apply:

Sound Bath Contraindications:

Pregnancy (particularly the first trimester)
Epilepsy or a history of seizures
Pacemakers or other implanted electronic devices

Breathwork Contraindications: (for deeper/active styles)

Severe/critical diseases or infections if it impairs your ability to breathe

Severe uncontrolled hypertension
Organ failure or late-stage terminal illness
Pregnancy
If you have epilepsy, a pacemaker, or irregular heart beat
Tinnatus
If any of these apply please make it clear on the waiver.

If you have any questions or concerns, please feel free to reach out before attending aswell.
Emergency Contact details*
Name & phone number required
Please describe your experience with Yoga/Breathwork/Sound Healing or other holistic practices?
In order to really get to know what you require from the sessions, please explain in as much detail as possible what your goals and motivations are?*
Marketing: Where did you hear about Serendía Wellness ?*
If word of mouth, please let me know who.
General Data Protection Guidelines: 'I' the student consent to 'Serendía Wellness' using my contact details to give me information and updates about any offerings. I understand that my personal details will be kept as securely as possible and never be passed to a third party.*
Disclaimer (Please Read Carefully) Some styles of Yoga can be strenuous and physically demanding. 'I', the yoga student, understand it is my responsibility to listen to my body and immediately stop performing any postures which cause pain.

It is important with all modalities offered such as Yoga/Breathwork/Sound Healing - that you listen to your body and respect its limits. 'I', the undersigned, understand that these modalities are not a substitute for Medical Attention, Examination, Diagnosis or Treatment.

It is my responsibility to seek the advice of a qualified medical professional before engaging in these sessions, particulary if there are current medical/health concerns.

I recognise that it is my responsibility to notify my ‘Instructor/Teacher/Practitioner’ of any serious illness or injury before the Yoga Session or if I am pregnant. 'I' will also inform my ‘Instructor’ of any future medical conditions which arise.

I am aware that emotional responses may be bought on (side effect) when engaging with practices that work with the bodies energies such as Yoga, Breathwork, Pranayama and Sound Healing.

I accept that neither the ‘Instructor/Teacher/Practioner’, nor the ‘Hosting Facility’ is Liable for any Injury, or Damages, to person or property, resulting from participating in these sessions.
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Date*

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I agree to all of the above and that i have been open and honest about my health*

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