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)

Height (cm)

Waistline/Abdomen (cm)

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 have any physical disabilities?

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

Do you have any cardiovascular disease?

Do you have any respiratory disease?

Do you have 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

Desired weight

The Pilates studio will provide the space, instructor, exercise program.

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

The client is required to complete/undergo our initial health/physical assessment done by our recommended Therapist.

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