Ghosh Therapy
consultation form

Please fill out the form below with as much detailed information as possible. The information you provide will be used to conduct further assessments and to develop a customized therapeutic program. 

 
Name *
Name
Date of birth *
Date of birth
Gender *
Height *
Are you currently under the care of a physician, chiropractor, or alternative medicine practitioner? *
Please check any fitness related activities you are currently engaging in:
Please check any that apply to you (currently or in the past):

Agreement to proceed: By submitting this form I agree to having completely disclosed all medical conditions that could impact the therapeutic advice I receive from Ghosh Yoga Cure. I understand that Ghosh Yoga Cure and teachers involved are not medical professionals. The decision to perform any exercise remains the individual’s and Ghosh Yoga Cure cannot accept responsibility for any problems that occur as a result of an individuals practice during, or outside of a Ghosh Yoga Cure consultation. If you are in any doubt or unable to clearly identify your current medical condition, please consult a medical professional before seeking our advice.