The Movement Studio Pilates & Structural Bodywork Agreement

Client Information
Full Name *

First Middle Initial Last
Date of Birth *

Month Day Year
Male or Female? *

Male Female
Address *

Street Address

Street Address Line 2

City State

Zip Code
Home Phone *
Cell Phone
Please enter a valid phone number.
Email *
example@example.com
Emergency Contact & Relationship *
Emergency Phone *
Medical History
Check the box next to each option if you have (or recently had): *

None Apply Arthritis Broken Bones Joint Pain Osteoporosis Severe Sprains Radiating pain in any limbs Numbness or tingling Heart Condition High Blood Pressure Hemophelia Pneumonia or other respiratory illness Diabetes Cancer Cyts or tumors Surgery Concussions Periods of dizziness Under Medication Wear Contact Lenses Currently Pregnant
Describe any other conditions or precautions:
Wellness and Prevention Services Agreement
I understand that the purpose of receiving Wellness/Prevention/Fitness services of Bodywork and Movement work is to balance and align my body. I recognize that I am a participant in a process not a patient in a medical procedure. I understand that the services of Structurally Integrative Bodywork and Movement work are not involved with the treatment of disease and not a substitute for medical diagnosis or treatment when such attention is needed.

Cancellations: I understand that sessions missed or cancellations with less than 24 hours notice may be subject to charges for time lost at a rate of $85.
Patient Name (Print) *
Date *

Month Day Year
Date
Signature of Patient or Guardian *

Clear
Medicare Beneficiaries only:

I understand that the services I am receiving are for Prevention/Wellness/Fitness and that these services are not covered by medicare.
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

Client Information

Medical History

Wellness and Prevention Services Agreement