Client Registration

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New Client Questionnaire
Basic Information About You

All fields marked with an * are required.

First Name
Last Name
Date of Birth
Phone Number
Health Questions
Do you have any injuries, aches, pains, or health conditions? Are they current or past? Please include any surgeries and their dates.
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Other Health ConcernsPlease choose all that apply.
Do you smoke?
Do you have any back pain?
If yes, please define.
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Are you currently taking any medications?
Please list any medications you are currently taking.
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What does your typical day involve physically? E.g. sitting at computer, lifting, standing for long periods, caring for children, etc.
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Are you presently doing other kinds of therapy? E.g. massage, physical therapy, chiropractic, etc.?
Please list any programs you are currently engaging in.
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Do you have any past training in the Pilates method of movement?
Please describe your Pilates experience.
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What are your goals? What do you want most from your Pilates training?
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Acknowledgement of Risk and Waiver of Liability

I understand that I will be participating in a fitness program through Pilates of Rochester that will require physical exertion. Before beginning this program, I was asked by my instructor whether I have any physical limitations, or whether I am taking any medications or receiving any medical treatment that might make it unsafe for me to participate in this fitness program. There is no such limitation, medication, or medical treatment other than those identified above that would make it unsafe for me to participate in this fitness program. I understand that, by agreeing to this statement, I am agreeing to not hold Pilates of Rochester or any of its employees, owners, agents, or insurers responsible for any bodily injury or property damage that may suffer as a result of my participation in a fitness program through Pilates of Rochester whether at Pilates of Rochester, at home, or elsewhere. As such, I understand and agree that Pilates of Rochester, its employees, owners, agents, or insurers shall not be liable for any bodily injury or property damage that may result either directly or indirectly from my participation in a fitness program through Pilates of Rochester .

Consent
Cancellation and Payment Agreement

Pilates of Rochester enforces a 24 hour cancellation policy. If a cancellation is not made by phone, text or email within 24 hours of the start of the session, the session will be charged in full.

I have read and understand the policy as stated.
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