Pilates Informed Consent Form

Name

First NameLast Name

Date of Birth

Date

Age

Gender

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Weight (lbs or Kg)

Height (ft)

Emergency Contact Person

First NameLast Name

Phone Number of Emergency Contact Person

Please enter a valid phone number.Format: (000) 000-0000.

Minors: Name of Parent/Guardian

First NameLast Name

Contact Number of Parent/Guardian

Please enter a valid phone number.Format: (000) 000-0000.

Have you been enrolled to any physical therapy before?

Are you currently pregnant?

Do you have any allergies?

If yes, please list down your allergies below and explain.

Do you currently have any injuries or are you experiencing any pain?

If yes, please list below and explain.

Do you have any cardiovascular disease/ respiratory disease/ asthma?

Did you undergo any recent surgery?

Do you have any medical condition that you would like to share? Please take note that this information is strictly confidential.

Health Insurance Policy No.

Wellness Goals

Fitness Goals

The Pilates studio (Isola Pilates in Crossfield, Alberta) will provide the space, instructor, fitness program for mat and Reformer Pilates, and may include lifestyle recommendations.

The client and both parties agreed to fully understand that physical exercise can lead to injury.

The client is required to complete/undergo our initial wellness/physical assessment done by Em Miiller, MH, ClH. Iridologist.

The client is responsible for disclosing any health limitations or concerns, past injuries, or current areas of concern in the body.

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

By signing below, it means that I agreed to the terms indicated in this document.

Date Signed

Date

Client Signature

Pilates Informed Consent Form

Personal Data

Health History

Fitness Tracker

Consent Agreement