Client Profile and Waiver

Today's Date

Date

Name

Birth Date(mm/dd/yy)

Date

Cell phone

Please enter a valid phone number.

Home Phone

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Accident/Injury History- Please include all current, past or chronic problems

Do you have or have you ever had:

Arthritis

Diabetes

Heart Problems

Joint Problems

Cancer

Fractures

Lyme Disease

High Blood Pressure

Osteoporosis

Glaucoma

Kidney Disease

Respiratory Problems

Please Explain:

Any Other Chronic Illnesses

Are you Pregnant:

YNN/A

Have you recently give birth:

YNN/A

Are you currently taking any medications

Are you currently under the care of a health care professional? If so, please explain

Do you have any specific health goals

What is your current Exercise Program

In case of emergency, please contact:

Relationship

Phone

How did you hear about us

Private sessions and group classes are non-refundable and require a 24-hour cancellation notice. Otherwiseyou will be charged for the session or class. To cancel please call our office at 203-604-9005. Private and semi-private sessions are valid for 12 months from date of purchase. Please initial indicating you understand this policy:

THE BODY REFLEX FITNESS & WELLNESS, LLC

WAIVER OF LIABILITY AND INFORMED CONSENT RELEASE

This Release, Waiver and Hold Harmless Agreement is made by and between the undersigned and The Body Reflex Fitness & Wellness, LLC and entered into on the day, month and year noted below. 1. The Body Reflex Fitness & Wellness, LLC provides space for and instruction in the Pilates Method and Personal Fitness Training. The parties to this agreement recognize that participation in the Pilates Method and other conditioning activities, like any physical conditioning activity or exercise program, presents some unavoidable risk of injury, especially to people who have pre- existing injuries, illness or medical disabilities. I understand that the use of exercise equipment also carries with it a risk of injury. 2. Client desires to undertake The Body Reflex Fitness & Wellness, LLC program with the full knowledge of the possibility that physical injuries could result from it and assumes the risk of any such injury. 3. The parties recognize that The Body Reflex Fitness & Wellness, LLC will not be able to and will not provide its program to Client without the execution of this agreement and our detailed Client Profile. A medical evaluation is advisable before commencing any program of physical conditioning exercise. I have and will continue to keep The Body Reflex Fitness & Wellness, LLC informed of any physical condition or disability, which would prevent or limit my participation in an exercise program.

Therefore, Client in consideration of the above and of the exercise instruction to be provided, hereby waives all claims for damage or loss to person or property which may be caused by an act or failure to act, of The Body Reflex Fitness & Wellness, LLC. Client assumes the risk of all dangerous conditions in and around the premises and waives any and all specific notice of the existence of such conditions. Client also assumes the risk of any and all injuries that might result from participating in The Body Reflex Fitness & Wellness, LLC exercise programs. In consideration of my participation in The Body Reflex Fitness & Wellness, LLC exercise program, I, for my heirs and assigns, hereby release The Body Reflex Fitness & Wellness, its employees and owner from any claims, demands and causes of action arising from my participation in the exercise program. I hereby affirm that I have read and fully understand the above and I am over 18 years of age.

Insert full name to agree to above terms.

Today's Date

Date

Type a question

Client's Signature

Client's Name (please print)