Clone of Client Request

1

Full Name* This field is required.

First Name

Last Name

2

Date Of Birth* This field is required.

3

E-mail* This field is required.

example@example.com

4

Phone Number* This field is required.

5

Emergency Contact Name

First Name

Last Name

6

Emergency Contact Number

7

Have you done Pilates before?* This field is required.

YESNO

8

Are you currently doing any other exercise?* This field is required.(e.g. gym, yoga, walking)

9

Health & Injury information* This field is required.Please tick any that apply and give details if needed.

Back pain or injury

Neck or shoulder issues

Hip, knee or ankle issues

Pelvic floor concerns

Recent surgery (within last 12 months)

Pregnancy or postnatal

Other medical condition (please specify)

None

10

If other selected please specify

11

Current Wellbeing - Do you experience pain during daily movement or exercise?* This field is required.

YESNO

12

Are there any movements you avoid or find difficult?* This field is required.

YESNO

13

If yes please specify

14

Photo & Video Consent

I consent to photos and/or videos being taken during classes and used for promotional purposes (e.g. social media or website)

I do not consent

15

Consent & Acknowledgement* This field is required.

I confirm that the information provided is accurate to the best of my knowledge

I understand that Pilates involves physical movement and I will work within my own limits

I agree to inform the instructor of any changes to my health or injuries

16

Signature* This field is required.

17

Date* This field is required.

Date