PRE-NATAL MEDICAL RELEASE FORM
 

1.  Name:_____________________________________

2.  Date of Birth:________________________________

3.  Expected Due Date:___________________________

4.  Email Address: ______________________________

5.  Describe any medical problems or conditions associated with your pregnancy:      ____________________________________________________________________________________________________

6.  Describe any and all non-pregnancy related medical problems that you have had in the past or are currently experiencing.
____________________________________________________________________________________________________

7.  List all previous Yoga experience (Please note if you have never done Yoga before):
____________________________________________________________________________________________________

8.  ObGyn/Midwife:_______________________________________

9.  Weeks of Gestation:____________________________________

10.  Anticipated Place of Delivery:_____________________________

11.  Emergency Contact:____________________________________

12.  Home Phone:_________________        Work/Cell Phone:____________________

13.  I, ____________________________ (ObGyn/Midwife), am providing prenatal care to ___________________________ (Patient) and declare that the above information is true and correct. ___________________________ (Patient) is of sound medical and prenatal health, and has my permission to participate in the prenatal yoga program offered by Experience Yoga Studios,
ObGyn/Midwife Signature:_______________________________    Date:________________

 

14.  I, ____________________________ (Student Signature), understand that Experience Yoga Studios, can not make a determination about the safety of the prenatal yoga class for each individual woman and her unborn child. My ObGyn/Midwife can only make such a determination and has stated his/her approval in the above paragraph. I therefore, release Experience Yoga Studios, of any and all liability for any medical contingency that may occur to either my unborn child or myself.

 

15.  I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above.

 

Student Signature:____________________________________      Date:__________________