Email Address

Occupation

Current Condition/Chief Complaint

Tell us about any injuries, limitations, or symptoms you have had

Emergency Contact Relationship to You

If you selected another client, please tell us their name below so they can receive referral points!

If there are any other reasons or additions you'd like to make to the above checklist, please explain them below

Social and Health Habits

Avg # drinks/week

Describe exercises beyond daily activities

# days/week

# minutes

What were the above clinical tests taken for?

List any prescription or over the counter medications you take

Release and Liability Waiver

The participant recognizes that participation in a sport, physical exercise, and physical therapy may result in accident or injury and the participant assumed the risk connected with this participation. Participant is in good health and does not suffer from any significant physical impairment, which would compromise their safety of use of Pilates MN's facilities. I understand and voluntarily accept this risk. Participant specifically agrees that Pilates MN, its officers, independent contractors, employees, and agents shall not be liable for any claim, demand, cause of action of any kind whatsoever for, or on account of death, personal injury, property damage or loss of any kind resulting from or related to Participant's use of the facilities or participation in exercise or activity within or without the studio premises, and Participant agrees to hold Pilates MN harmless from same. I authorize Pilates MN physical therapists and trainers the freedom to share medical or physical issues I may have to further benefit my therapy and healing. This authorization may be cancelled by me in writing at any time. I understand Pilates MN's cancellation policy for all privates and classes is 24 hours, however, 48 hours is preferred so that we can fill that space. This policy is industry standard and respects the time, preparation, and schedules or both our trainers and fellow clients. I understand that Pilates MN is not responsible if a client contracts COVID-19. The guidelines that are currently in place are in compliance with the guidance of the CDC. I sign this agreement on my behalf and on behalf of my minor children who may visit the studio.

Pilates MN Health History Questionnaire and Release and Liability Waiver

connect With Us on Social Media