Fill Out The Form Below To Be on Your Way To A Healthier You!
Medical Clearance and Release of Liability
I certify that I am in good health and if that condition changes, I will notify Cheryl at Kinect Pilates.
If, in the event a medical clearance must be obtained prior to my participation in an exercise program or fitness assessment, I will allow Kinect Pilates to consult my physician and obtain written permission prior to the commencement of any exercise program.
In consideration for being allowed to participate in an exercise program, I agree to assume risks of such exercise, and further agree not to hold Kinect Pilates liable while Cheryl conducts the exercise program from any and all claims, losses, suits related cause of action for damages incurred during or rising in any way from the exercise program.
Filling in and submitting the form below will serve as your signature or agreeing to and understanding this release!
Business Policy
Kinect Pilates services are payable in cash or cheque in advance of services rendered. Cheques are payable to: Cheryl Reynolds.
Exercise Sessions last for 60 minutes. Please be ready to begin each training session at your scheduled appointment time. If you are late, the training session will not be extended.
Sessions purchased are non-refundable and should be used no less frequently than one session per week (unless away on holidays or for programs). If you become ill or injured and have been advised by a physician to temporarily discontinue training, sessions will remain valid for a period of up to 12 months.
Should you wish to reschedule an appointment, Cheryl will do her best to accommodate your request. Should she be unable to find an alternative time slot, and the request is placed less than 24 hours prior to the appointment you will be charged for the appointment.
A 24 hour notice of cancellation is required should you wish to cancel a training session. Canceling with less than 24 hours notice will result in a charge for the appointed workout.
Filling in and submitting the form below will serve as your signature for agreeing to and understanding Cheryl’s business policies.
INTAKE CONSULTATION
Identification
Name: ________________________ Date of Birth: ____________ Age:_____
E-mail address: ____________________________
Street address: ____________________________
City: _____________________________________
Postal Code: ______________________________
Phone: (H)_______________ (W)_____________ (C)_____________
Occupation: ________________________________
Physician’s name _________________________________Phone_____________
Emergency Contact ________________________________Phone_____________
When is the best time to contact you?
Morning
Afternoon
Evening
Why are you interested in Pilates at this time?
Do you currently, or have you ever had heart problems? Yes No
Do you have high blood pressure? Yes No
Have you ever had a stroke or heart attack? Yes No
Have you ever had pain in your chest? Yes No
Do you ever feel faint or have dizzy spells? Yes No
Have you had surgery in the last 6 months? Yes No
If yes, explain.
Existing Medical Conditions – Please check the appropriate conditions
Diabetes Pregnancy Asthma Arthritis
Heart Condition Obesity Epilepsy Cholesterol
Hernia Anemia Ulcer Eye Problems
Hearing Loss Thyroid Problems
Medications
Are you currently taking any medicine? Yes No
If you circled YES, please list the medication and for what condition
Do you have pain in or have you injured any of the following areas:
Neck Upper Back Lower Back
Shoulder R/L Elbow R/L Wrist R/L
Hip R/L Knee R/L Ankle R/L
If yes to any of the above, please explain:
Current health and fitness activities (e.g. walking/hiking/biking/weight training):
What are your health and fitness goals?
1.
2.
3.
Do you have regular treatment from any of the following individuals?
General Practitioner (annual) Chiropractor Massage Therapist
Dietician Physiotherapist Acupuncturist Naturopath
Other
Are there any other reasons (health or personal) that may limit or prevent you from exercising?
How did you hear about Kinect Pilates?
I agree to all of the above Policies
Yes No
Client Signature _____________________________________ Date _______________________
Client Name _________________________________________