Client Intake Form

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Best Phone Number to Reach You. *

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Preferred Contact Method

PHONE

TEXT

EMAIL

Emergency Contact Phone Number *

(###)

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What would you like to focus on during your Pilates session?

SELECT AS MANY AS YOU LIKE

FLEXIBILITY

ENDURANCE

STRENGTH

WEIGHT LOSS

REHABILITATION

SPORTS CONDITIONING

STRES MANAGEMENT

PAIN REDUCTION

OTHER

What level of intensity do you work out?

VERY LIGHT

LIGHT

MODERATE

MIXED MOD/HEAVY

Are you pregnant?

YES

NO

Do you have biological children?

YES

NO

Do you currently have or have the history of the following:

LOWER BACK ISSUES

UPPER BACK ISSUES

NECK PROBLEMS

DISC ISSUES

SCOLIIOSIS

SCIATICA

HIP, KNEE, ANKLE ISSUES

FOOT ISSUES

SHOULDER ISSUES NAD/OR DISLOCATIONS

DIFFERENCE IN LEG LENGTH

TENDON/MUSCLE/LIGAMENT ISSUES

ARTHRITIS

JOINT REPLACEMENT

OSTEOPOROSIS

HEADACHES

NEUROLOGICAL CONDITIONS

NUMBNESS/TINGLING

VERTIGO/DIZZINESS

HOW/LOW BLOOD PRESSURE

HEART DISORDER

SEIZURES

DIABETES

CANCER

ABDOMINAL SURGERY

OTHER CONCERNS OR ISSUES

The risk of injury from activities in this program is significant, including potential for permanent paralysis and death, and while particular rules, equipment and personal discipline may reduce the risk, the risk of serious injury does exist. *

I ACKNOWLEDGE

And, I am aware that it is my responsibility to inform my instructor of any preexisting conditions before participating in any studio with The House-Pilates activities. I further understand that The House- Pilates holds no liability regarding such pre-existing conditions. *

I ACKNOWLEDGE

I agree to inform my instructor of any new injuries or conditions (including pregnancy) and I agree that I am freely participating in the Studio with Monique. activities with these known conditions I assume full responsibility for my participation. I assume all risk and understand it is my responsibility to consult a doctor about participating in these activities. *

I ACKNOWLEDGE

I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of others, and assume full responsibility for my participation. *

I ACKNOWLEDGE

I agree to comply with "The House-Pilates" conditions of participation, and abide by her Studio's policies, including health and safety policies. While participating in Pilates with Monique, I agree to report any hazard, safety issue, and will act to avoid injuring myself, or others, in case said hazard occurs. *

I ACKNOWLEDGE

I understand there is a 24 hour cancellation policy for private sessions, and that I will be charged/deducted class in full if I fail to provide appropriate notice. *

I ACKNOWLEDGE

I understand a "no show" results in full charge/session deduction. *

I ACKNOWLEDGE

All sessions and packages expire 90 days from purchase date. *

I ACKNOWLEDGE

No refunds, only studio credit. *

I ACKNOWLEDGE

I have read this release of liability and assumption of risk agreement and fully understand I assume all risk for undertaking The House-Pilates activities. I understand I have fully given up substantial rights by signing and agreeing to these terms. I attest that I am signing this agreement freely and voluntarily, without any inducement. *

I ACKNOWLEDGE

Date *

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DD

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