Postnatal Mat Pilates - Small Group- Health Screening and Booking Form
(Pilates with Veronika)
WEDNESDAYS 11AM- 12PM @PORTFIELDS COMMUNITY CENTRE, NEWPORT PAGNELL, MK16 (Please bring your mat. All other equipments will be provided.)
Booking options (Please choose the date/dates below. Free cancellation/rescheduling by 12pm the day before the session.)
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Single Session (£13)
4-Week Block (£44)
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Name
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First Name
Last Name
Date of birth
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Email
example@example.com
Baby's age/ Date of birth:
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How many weeks postpartum are you?
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Type of delivery:
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Vaginal
C-section
Have you had your 6-8 week GP check-up?
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Yes
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Did your GP/midwife give you the "all clear" for exercise?
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Yes
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Are you aware of any abdominal separation (Diastasis Recti)?
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Yes
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Unsure
Are you experiencing any heaviness, leaking, or discomfort?
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Yes
No
Did you experience any significant tearing or have any lingering stitches/scar pain? (Please describe):
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Are you currently breastfeeding/chestfeeding?(Note: This is helpful for me to know regarding wrist/shoulder tension and hydration needs!)
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Yes
No
Are there any other medical conditions or injuries I should be aware of? If so, please give me more details.
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1. Physical Readiness & GP Clearance I confirm that I am at least 6 weeks postpartum (or 10–12 weeks if I had a C-section) and have received the "all clear" to return to exercise from my GP or Midwife at my postnatal check-up. I agree to inform Veronika immediately of any postnatal complications, such as increased bleeding, pelvic pain, or dizziness.2. Specialist Nature of the Class I understand that this class is a Specialist Small Group (maximum 8–10 participants) designed specifically for postnatal recovery. I acknowledge that while the exercises are tailored for safety and core rehabilitation, it is my responsibility to monitor my own body. If I feel any pain, heaviness in the pelvic floor, or discomfort, I will stop the exercise immediately and inform the instructor.3. Assumption of Risk I understand that any physical activity carries a small risk of injury. I voluntarily assume all risks associated with my participation in this class and agree that Veronika Molnar (Pilates with Veronika) shall not be held liable for any injuries or complications, provided the instruction was given with reasonable care and within the scope of a qualified Postnatal Specialist.4. Booking & Cancellation Policy * Payment: My space is only secured once payment (£44 for the block or £13.50 for a single session) is received via bank transfer.Cancellations: I understand that to reschedule or cancel a session, I must notify Veronika by 12:00 PM (midday) the day before the class. Failure to do so will result in the loss of that session fee.Make-up Sessions: Subject to availability, I may attend a regular Pilates session within the same week if I cannot attend the Postnatal class. Please don't bring babies/kids to the class.5. Informed Consent I have read this form in its entirety and understand its contents. I am signing this freely and voluntarily.
Thank you for completing this form. I will contact you shortly with the payment details. Please note, you don't need to fill in this form again for future bookings. Bookings could be done via our private WhatsApp group or personally.
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AGREE
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