Name *

First Name

Last Name

Phone *

(###)

###

####

Birthday

MM

DD

YYYY

Have you ever been treated by a physician for: *

None

Chronic Fatigue Syndrome

Diabetes

Fibromyalgia

Heart Diesease

High Blood Pressure

Gastric Reflux (GERD)

Glaucoma

Multiple Sclerosis

Orthopedic/Joint issues (shoulder, hip, spine, knee, ankle, foot)

Osteoporosis

Osteopenia

Peripheral Neuropathy

Parkinsons

Rheumatoid Arthritis

Arthritis

Reconstruction

Reconstruction

Pregnancy

Pregnant Yes

Pregnant No

Post delivery under six weeks

Had a Caesarean section

Do you have neuromuscular, musculoskeletal, or prior injuries?

Adhesive Capsulitis (Frozen Shoulder)

Carpel Tunnel Syndrome

Plantar Fasciitus

Rotator Cuff Impingement

Scoliosis

Thoracic Outlet Syndrome

Joint replacement

ACL repair

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cancelation Policy *

I'm honored that you trust me with your health, time and fitness. I will do my best to accommodate your schedule. In respect our time, I must (pre) plan accordingly, start and finish on time. Therefore I must stress the 24 hour advance notice cancellation policy or you will be charged full price for the session.

I agree to the 24 hour advance cancellation policy.

Risk *

I will receive information and instruction while participating in the class at Bett Pilates. I recognize that this class will require physical exertion, which may be strenuous and may cause physical injury and I am fully aware of the risks and hazards involved.

Yes

Responsibility *

I understand that it is my responsibility to consult with a physician prior to and regarding my participation in this class or any other activity associated with Hilary Opheim Pilates. I represent and warrant that I am physically fit and I have no medical conditions, which would prevent my full participation in the Pilates workout. If I have any medical conditions they are listed clearly and accurately on the Client Information form and will be updated yearly or sooner in writing.

yes

Injury/ Damage *

I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I may incur as a result of participating in the program.

Yes

Waiver *

I knowingly, voluntarily and expressly waive any claim that I may have against Bett Pilates for injury or damages that I may sustain as a result of my participation.

yes

Representations *

Heirs, my legal representatives or I, forever release and waive any liabilities against Bett Pilates for any injury or death incurred by my voluntary participation in this class

Yes

Photos *

I agree to allow Bett Pilates to use my likeness in publicity, websites and social media. I may revoke this privilege at any time in writing

Yes

No

Reading and Understanding *

I have read the above releases and waivers and fully understand its contents. I have filled out my medical information honestly and completely.

Yes

Today's Date

MM

DD

YYYY