Pilates Waiver - Pilates Fitness & Physical Therapy Center

Pilates Waiver / Intake Form

Name(Required)

First Last

Gender(Required)

Male

Female

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Phone(Required)

Email(Required)

Emergency Contact

Name(Required)

First Last

Phone(Required)

Relationship(Required)

How did you hear about us?(Required)

Health - Please list any physical or medical conditions and/or limitations that you now have or have had* (including but not limited to Neck, Spine, Shoulder, Hip, Knee, Foot/Ankle, Neurological, ACL, Injuries, Surgeries, Replacements etc.) Please explain.

Are there any health concerns?* Including but not limited to Asthma, Diabetes, High Blood Pressure, Heart Disease, etc. If Yes, please explain.(Required)

Please list any medication(s) and supplement(s) you are taking and explain why.(Required)

Have you seen or had any chiropractic, osteopathic adjustments for any reason?* If yes, please explain.(Required)

Do you have Osteoporosis or Osteopenia?(Required)

Have you had any training in Pilates, GYROTONIC®, or Power Plate?* If so, when, where?

What are your goals?(Required)

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Pilates Waiver / Intake Form

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