Pilates Informed Consent Form
Personal Data
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Age
Gender
Male
Female
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Person
First Name
Last Name
Phone Number of Emergency Contact Person
Please enter a valid phone number.
Format: (000) 000-0000.
Have you been enrolled to any physical therapy before?
Yes
No
Which Classes are you interested in joining
Chiswick, Monday 7pm
Whitton, Tuesday 1pm
Whitton, Wednesday 7.30pm
Teddington, Thursday 7.45pm
Zoom classes (Timetable available on request. You have 8 weeks to use the sessions)
1:1 session (I will call you to discuss booking times)
Health History
Are you currently pregnant?
Yes
No
Do you have any allergies?
Yes
No
If yes, please list down your allergies below and explain.
Do you have any physical disabilities?
Yes
No
If yes, please list down your disabilities below and explain.
Do you have any cardiovascular disease?
Yes
No
Do you have any respiratory disease?
Yes
No
Do you have asthma?
Yes
No
Did you undergo any recent surgery?
Yes
No
Do you have any medical condition that you would like to share? Please take note that this information is strictly confidential.
Fitness Tracker
Wellness Goals
Fitness Goals
Payments must be made before the class Bank Details- Bryony Ashford First Direct 40-47-82 63944522 **************************"*************** I require at least 24 hours notice for any cancellations. Cancellations within 24 hours will still be charged.
I have paid £7 for a trial
I have paid £78 for the 6 week term
I have paid £54 for the 6 week zoom term
I have paid £70 for a 1:1 session
Consent Agreement
Date Signed
-
Month
-
Day
Year
Date
Client Signature
Submit
Submit
Should be Empty: