First Name

Last Name

Phone *

Email *

Address *

City *

Postal code *

Date of birth *

Occupation *

Any thing else you would like to share about your health? *

On a scale of 1-10, how physically active is your lifestyle currently (10 being the most active)? *

How did you hear about Resilo®? *

Prittie Yoga, Emily Perrier, does not accept responsibility for any health difficulties that may arise from not seeking professional medical advice or treatment. Resilo® is a non-medical, gentle, but precise assessment of the body when there are aches and pains or need to aid recovery. Not intended to replace standard medical treatment. Practitioners do not diagnose conditions nor perform chemical treatment. It is normal to feel some discomfort for 24-72 hours as the repair process.

Tick if you are in agreement. N.B. Emily is unable to treat you this box is unticked.

Yes, Emily can contact me by email and subscribe me to Prittie Yoga's newsletter. I understand that Emily will never share my email or contact details with anyone else.

Yes

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