NAME
:
BORN ON
:
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Year
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
PHONE
RESI.
:
OFFICE
:
MOBILE
:
FAX
:
EMAIL
:
TYPE OF YOGA
:
RADIANCE HATHA YOGA
WEIGHTWATCHERS HATHA YOGA
DESKTOP YOGA FOR STRESS RELEASE
PRENATAL & POSTNATAL YOGA
ANIMAL YOGA
YOGA AT HOME
RADIANCE POWER YOGA
WEIGHTWATCHER'S POWER YOGA
POWER YOGA INTENSIVE
MIXED HATHA-POWER PACKAGE
THERAPEUTIC YOGA
INDIVIDUAL / LADIES ONLY / FAMILY PACKAGE
ADVANCED YOGA
MEDICAL HISTORY
:
MEDICATION
:
COMMENTS
:
PREF. TIME SLOT
:
AM
PM
TRAVEL PLANS(S)
:
DIET INDICATION
:
MILK PRODUCT
:
YES
NO
ANY OTHER EXERCISE PROGRAM
:
YOUR PHYSICIAN
:
WHAT DO YOU WANT TO GET OUT OF THIS PROGRAMME
:
PREFD. COLOURS
:
YOUR GEMSTONE
:
SMOKING
:
NO
YES
HOW MANY A DAY ?
DRINKING
:
NO
YES
WHAT DRINK ?
MODE OF PAYMENT
CASH
CHEQUE
CREDIT CARD
(For Credit Card, kindly click on CREDIT CARD, fill up the form, take the printout and fax it back to us)
