Name *

First Name

Last Name

Have you suffered or do you suffer from any of the following? *

Please tick all that apply and give further info below where relevant

High Blood Pressure

Low Blood Pressure

Cardiac Problems

Asthma

Skin Disorders

Arthritis

Phlebitis

Varicose Veins

Epilepsy

Other

None of the above

Please tick the boxes below to confirm you have read this information and that you consent to what is described. *

I take full responsibility for my own health and well-being during this yoga holiday.

I confirm that all of the information given is true and correct. Yoga health Mandala Ltd. will not be held responsible should any undisclosed information later be proved to have affected any services given.

I understand that I am responsible for having adequate travel insurance, and that Yoga Health Mandala Ltd. will not be held responsible for any damage or injury sustained during activities that take place outside of the retreat space.

I confirm that I have read the Privacy Policy visible on the website, and Booking Terms & Conditions and agree to the practices described therein.

I understand that the online submission of this form replaces my signature and I consent to my health questionnaire being stored digitally on a password protected device.