MOMA RESTORE Registration Form

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Congratulations on the arrival of your new bundle! Thank you for taking the time to fill out this form. It's important that you give as much detail as you can so I can get to know you better and have an idea of how I can best support with your recovery during this early postnatal period and beyond! Thanks Goretti

All information contained within is strictly confidential and will not be shared with a third party. By completing this form you are giving consent for us to safely store your data, which we are required to do by law.

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Your Name* This field is required.

First Name

Last Name

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Your Date of Birth* This field is required.

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E-mail* This field is required.

example@example.com

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How/Where did you hear about us?* This field is required.

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Do you give consent to be contacted by Pilatesnow.ieYou may change your mind and unsubscribe from our contact lists at anytime, don't worry we won't bombard you

YESNO

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Baby's name* This field is required.

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Baby's Date of Birth* This field is required.

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Feeding?* This field is required.

Breastfeeding

Bottlefeeding

Combination Feeding

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Please state your general health* This field is required.

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Do you have any injuries, aches or pains? (recent or old) * This field is required.Please describe

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What kind of delivery?* This field is required.

Vaginal

Cesarean

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If there is anything about your birth experience (or previous birth experiences) or after that you would like us to be aware of, please elaborate here* This field is required.complications, long labour, fast labour, episotomy, stitches, tears, infection, trauma, positive experience etc

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Do you feel you have any dysfunction, pain or weakness in your pelvis, pelvic floor?* This field is required.E.g. leaking, urge incontinence, frequent urination, constipation, pain, heaviness, pulling, pain, pain during sex, something not feeling right

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How is your overall feeling of well-being? How are you coping?* This field is required.overwhelmed, anxious, sad, baby blues

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Any other questions, concerns or information?we welcome your questions

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Please read the following for your information

Our MOMA RESTORE programme consists of self pased classes. These classes will begin at a low level and will become pregressively more challenging. If you experience any fatigue, discomfort or weakness, please stop, rest and inform your care giver, if any issues persist. You can always contact Goretti, if you'd like any advice.

Although we would encourage active participation and enthusiasm, please do not feel you have to participate in every exercise if you feel you are unable to - Listen to your body, this is so important! Please spend some time with each class, and try to include mindful movement in your day. Once you are happy that you can comfortably complete a class and you feel you are ready, then please move onto the next class.

Also ways remember that slow progress at this stage means faster, better recovery long term. So please be patient with your self. This doenst mean do nothing!!! You are hear to recover and build stretnght after all!

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PILATES PARTICIPATION INFORMED CONSENT

You must agree to the client disclaimer below before participating in our classes.
Every precaution will be taken to ensure your safety during participation in these
classes. With that in mind, you are aware of the risks involved.

You agree that certain elements of the classes will be physically demanding.

You agree that you are physically capable of participating in the sessions and accept
full and complete responsibility for your own participation in the class.

You agree that should any medical or physical problem arise prior to or during a class which is likely to affect your ability to participate in a class this includes pregnancy.

I agree to the terms and conditions stated above.

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* This field is required.

I have read and understood the terms and wish to proceed

I have read and understood the terms and do not wish to proceed