New Client Form » Pure Form Pilates & Physiotherapy Studio Avalon

Pure Form Pilates Client Personal Details & Waiver

If possible, please fill out & submit this form at least 24 HOURS BEFORE your first session, so that we have a chance to read it, & print it out for your file. Thank you.

"*" indicates required fields

Name*

Preferred Name

Address*

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

Phone*

Email*

Date of Birth*

Occupation*

Emergency Contact (Name & Phone)*

How did you hear about Pure Form Pilates Avalon?*

Recommendation by friend / family

Recommendation by practioner

Web search

Facebook

Instagram

Referring Practitioner (if applicable)

Health Fund Name

Goal / Restrictions / Injuries

Goals / Expectations for starting sessions with us*

Current Injuries / Conditions / Restrictions*

Do you currently have pain anywhere in your body? If so, where?*

Current Exercise*

Previous Pilates Experience: (Timeframe / Which studio / matwork or equipment based sessions etc)

Medications (if applicable)

Any other practitioners (eg: physio, osteo, GP, naturopath) that you are seeing for above issues

Females: Do you have children? If so, how many? Birth & baby history (eg: pelvic floor issues prenatally or postnatally, natural or caesarian births, etc....)

Is there anything else that you think we should know about?

From time to time we may take video or photo footage in the studio for social media and marketing purposes. Do you give us permission to use photos or videos containing you on social media?

Yes

Cancellation Policy

This studio has a strict 24 hour cancellation policy. If you are unable to attend a booked session for any reason, please contact us and give 24 hours notice of your cancellation or your full session fee will be charged. Cancellations are accepted during office hours only (Mon – Fri 8am-6pm, Sat 8am – noon). Any cancellations received outside of these times will be registered upon opening the following business day. Any cancellation by Pilates Instructor must be made with 24hours notice also. Failure to do so will result in a complimentary session to the affected client.

Client Waiver

I understand that I undertake this exercise program and use all the facilities and equipment in the Pilates studio at my own risk. Prior to exercising I must disclose any health conditions and have obtained clearance from my general practitioner with regards to such conditions. I take it upon myself to discuss any changes to my current health with my Pilates instructor. I recognise that the instructor is not able to provide me with medical advice with regard to my medical fitness and that the information provided is used as a guideline to the limitations of my ability to exercise. I have answered the above questions to the best of my ability.

Signature*

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