Section 1 of 1
Liability
Waiver & New Client Intake + History Form
Click the below link to access the Liability Waiver. Download the document, fully complete, and sign. Then upload the completed document below (via the add file button). Complete the remaining of the form (New Client Intake + History Form) as well. This is required prior to attending your pilates class. Thank you for your time! We can't wait to see you. God bless!
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First & Last Name
First & Last Name
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Phone Number
Phone Number
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Email Address
Email Address
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Address
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Billing Address
Billing Address
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Using the email provided, would you like to receive (occasional) information about studio news and events?
Using the email provided, would you like to receive (occasional) information about studio news and events?
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Yes
No
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Emergency Contact + Relationship
Emergency Contact + Relationship
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I'd love to get to know you better. What professional and personal interests and responsibilities influence your health and movement function? What inspired you to try Pilates with me?
I'd love to get to know you better. What professional and personal interests and responsibilities influence your health and movement function? What inspired you to try Pilates with me?
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Do you have any activities you want to support through Pilates? (athletic endeavors, arts/music, caregiving, labor)?
Do you have any activities you want to support through Pilates? (athletic endeavors, arts/music, caregiving, labor)?
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Are you recovering from an injury or illness / Challenged by specific limitations or chronic pain?
Are you recovering from an injury or illness / Challenged by specific limitations or chronic pain?
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Have you been treated by a Physician for any of the following? *Check all that apply.
Have you been treated by a Physician for any of the following? *Check all that apply.
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Arthritis
Back pain or injury
Cancer
Chronic Fatigue Syndrome
Diabetes
Diastasis Recti (abdominal separation)
Ehler's Danlos Syndrome or Hypermobility Spectrum Disease
Fibromyalgia
Heart Disease
High or Low Blood Pressure
Gastrointestinal Disorders or Disease
Glaucoma
Multiple Sclerosis / Parkinson's Disease / Other Neurological Disease
Orthopedic / Joint Problems
Osteoporosis / Osteopenia
Pelvic Floor dysfunction or injury
Peripheral Neuropathy (numbness/tingling/loss of sensation)
Rheumatoid or Psoriatic Arthritis
Thoracic Outlet Syndrome
Stroke
Vertigo
N/A
Other:
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What types of activities, movements or positions cause discomfort? On the flipside, when do you feel your best?
What types of activities, movements or positions cause discomfort? On the flipside, when do you feel your best?
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Back Injury: Specify what area of the spine is affected and check any that apply.
Back Injury: Specify what area of the spine is affected and check any that apply.
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Facet Joint Syndrome
Herniated, Bulging or Extruded Disc
Scoliosis
Spondylolisthesis
Stenosis
SI Joint Pain
Other: tethered cord / cysts
N/A
Other:
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Orthopedic/Joint Problems. Check all that apply
Orthopedic/Joint Problems. Check all that apply
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Shoulder
Arm or Hand
Hip
Knee
Ankle
Foot
Ribcage
N/A
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Have you had any surgeries or radiation?
Please specify as best you can. It's all relevant to your movement experience!
Have you had any surgeries or radiation?
Please specify as best you can. It's all relevant to your movement experience!
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Physician / PT clearance for Pilates
If you are recovering from an injury or surgery, please specify when your physician or PT cleared you for exercise, and whether they spoke about contraindications.
Physician / PT clearance for Pilates
If you are recovering from an injury or surgery, please specify when your physician or PT cleared you for exercise, and whether they spoke about contraindications.
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Do you have any allergies and/or do you carry any medications I should know about?
**If you have severe allergies and carry an Epi Pen, please make sure I know where to find it for you in case of an emergency.
Do you have any allergies and/or do you carry any medications I should know about?
**If you have severe allergies and carry an Epi Pen, please make sure I know where to find it for you in case of an emergency.
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Policy Agreement: Please confirm that you have read, understand, and agree to our 24-hour Cancellation Policy, and Package Refund and Expiration Policy.(required)
I have read, agree, and understand that appointments booked with Healthy Soul Pilates, which is a private practice, have a 24-hour Cancellation Policy, and that appointments I've cancelled within 24 hours of my scheduled lesson may be charged the full cancellation fee. Furthermore, I agree to respect the studio's expiration policy for non-commitment package and the required 30 cancellation notice required to cancel memberships.
Policy Agreement: Please confirm that you have read, understand, and agree to our 24-hour Cancellation Policy, and Package Refund and Expiration Policy.(required)
I have read, agree, and understand that appointments booked with Healthy Soul Pilates, which is a private practice, have a 24-hour Cancellation Policy, and that appointments I've cancelled within 24 hours of my scheduled lesson may be charged the full cancellation fee. Furthermore, I agree to respect the studio's expiration policy for non-commitment package and the required 30 cancellation notice required to cancel memberships.
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I agree.
I have extenuating circumstances and would like to discuss options for frequent late cancellations.
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