Client Info, Policies, & Activity Waiver

Client Info, Policies, & Activity Waiver

for OLIVIA ENG/MYOHO HEALING
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Gender

MaleFemale
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Weight (lbs)
Height (cm)
Emergency Contact Person

First NameLast Name
Phone Number of Emergency Contact Person
Please enter a valid phone number.
Minors: Name of Parent/Guardian

First NameLast Name
Contact Number of Parent/Guardian
Please enter a valid phone number.
Have you been enrolled to any physical therapy before?

YesNo
Health History
Are you currently pregnant?

YesNo
Do you have any allergies?

YesNo
If yes, please list down your allergies below and explain.
Do you have any physical disabilities?

YesNo
If yes, please list down your disabilities below and explain.
Do you have any cardiovascular disease?

YesNo
Do you have any respiratory disease?

YesNo
Do you have asthma?

YesNo
Did you undergo any recent surgery?

YesNo
Do you have any medical condition that you would like to share? Please take note that this information is strictly confidential.
Injuries/Concerns
Goals
Rates
ALL CLASSES ARE 50 minutes

The rates are a as follows:

PRIVATES:
Single Session: $120-130 sliding scale

4 pack: $460

DUETS:

Single Session: $65-75 per person sliding scale

INTRO PACK/NEW CLIENT SPECIAL:

$300/ first 3 sessions

(expires in 30 days from purchase)

WORKSHOPS

Price + duration of class will vary depending on workshop

*Rates are subject to change, and you will be informed in advance if so.
Policies & Procedures
Payments must be made prior to receiving services. Payment must be made upon booking and to hold the session. All sales are final. No refunds or exchanges.

Accepted forms of payment: Venmo, PayPal, Zelle, Check, Cash

Venmo:@olivia-eng

Paypal: oliviaeng.danza@gmail.com

Zelle: viiviiarte@gmail.com

Please arrive on time. You will still be charged for the full session if you arrive late or late cancel.

To cancel an appointment without charge, you must contact Olivia Eng/Myoho Healing at least 24 hours in advance of your scheduled appointment. If you fail to cancel 24 hours in advance, you will be charged for a full session. This is a strict cancellation policy, illness included.

Please utilize the following email as the main form of communication: MyohoHealing.Olivia@gmail.com
Activity & Informed Consent Waiver
Olivia Eng/Myoho Healing will provide the space, instruction, & exercise program.

I understand that I am required to complete/undergo an initial health/physical assessment.

I hereby affirm that I have read and fully understand the content below, am over eighteen years of age and am legally liable for my own decisions/actions.

I have been advised and I understand that participation in Pilates method exercises and conditioning activities, like any physical conditioning activity or exercise program, presents some unavoidable risk of injury, especially to people who have preexisting injuries, illness or medical disabilities. I understand that the use of exercise equipment also carries with it a risk of injury. I recognize that many changes may occur as a result of these exercise lessons, including possible shortterm aggravation of some symptoms, feelings of tiredness, lightheadedness, increased energy, mood changes, etc.

I also understand that a medical evaluation is advisable before commencing any program of physical conditioning or exercise. I have and will continue to keep my instructor Olivia Eng fully informed of any physical condition or disability which would prevent or limit my participation in an exercise or physical conditioning program.

I acknowledge that, although the conditioning program I participate in may have substantial physical benefits, Olivia Eng/Myoho Healing are engaged in diagnosing or treating medical diseases or deficiencies. I expressly assume all risks of my participation in the programs of Pilates method conditioning conducted by Olivia Eng/Myoho Healing and waive any claim which I might otherwise
bring against Olivia Eng/Myoho Healing as a result of injuries resulting from or relating to my participation in Pilates method conditioning programs.

Olivia Eng shall not be responsible or liable for any articles lost, stolen, or
damaged, in or about the studio. I understand that mat and semiprivate lessons require prior evaluation of my fitness level and that I am responsible for attending the appropriate level class.

By signing below, it means that I agreed to all of the terms indicated in this entire document.
Date Signed

MonthDayYear
Date
Client Signature

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Client Info, Policies, & Activity Waiver

Health History

Rates

Policies & Procedures

Activity & Informed Consent Waiver