Pilates Consent Form with Terms and Conditions - Physiotherapy ...

Physiotherapy + Pilates EvolvedPilates Client Consent and Information FormSECTION 1 - PERSONAL INFORMATION (Please complete all sections)FIRST NAME: LAST NAME: DATE OF BIRTH:PREFERRED NAME:ETHNICITY: MALE FEMALE NAME OF GP:STREET ADDRESS:SUBURB: CITY: POSTCODEHOME PHONE:CELLPHONE:HOW WERE YOU REFERRED: Website Family/friend Health professional Other (please specify)…………………………………………SECTION 2 - GENERAL HEALTH QUESTIONNAIRE: Pregnant Postnatal HIV/Hep C Physical disabilityMEDICATIONS – PLEASE LIST: Cardiovascularcondition Skin condition Cancer Hearing/sight impaired Intellectual Disability Other (Specify)………………………………………..Office Use Only:ENTERED: Asthma/Respiratory Circulation Allergy (Specify)…………………………………………SECTION 3 – EXERCISE SAFETYDo you currently have any health issues or injuries that could affect your ability to exercise safely?YES/NO. If you are pregnant or have just had a baby please let us know your dates and anycomplications/concerns……………………………………………………………………………………………….……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..What aspect of your health would you like to focus on? (Please tick as many as you feel is achievable)Identify, on the chart below, areas youlike to improve on.Strength Relaxation FlexibilityStress Reduction Posture Other……………………………………………What previous Pilates experience have you had? (I.e. mat, equipment, one on one, class)………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………SECTION 4 – CONSENTSI, the undersigned, agree to follow the safety instructions of my instructor and to inform them immediately should I have anypain or concerns during Pilates. I agree that I do not have any injuries, chronic problems or physical ailments which wouldprevent me from undertaking Pilates in a class environment and that I take this Pilates class at my own risk.I agree not to hold the Pilates Instructor or Physiotherapy and Pilates Evolved Ltd liable for any injuries that may arise fromattending Pilates.I understand that clients are required to give 24 hours notice of change or cancellation of booked sessionsotherwise I will be charged for the missed session. This includes private and semi-private sessions. Norefund will be issued for missed mat classes that have been block booked in advance.SIGNED:(If under 16 must be signed by parent/guardian)DATED:Please see over page for terms and conditions

Please initialPhysiotherapy and Pilates Evolved Terms and ConditionsAll fees are payable in advance or at the time of the session.24 hour notice of change or cancellation of booked sessions is required otherwise you will be charged forthe missed session.Sessions are not transferable to other clients, friends or family.If you are unable to attend your normal class, you may make up this session by attending a different class time beforeyour expiry date. This is dependent on space availability in the other classes.In the event that we cancel a session that you have booked, we will contact you by telephone, text or e-mail and thissession will be added to the end of your block.Physiotherapy and Pilates Evolved will ensure that all our clients are notified in person, by email, text or phone,regarding any changes in Terms and Conditions or pricing.Please tick the box that applies to youTerms and Conditions related to specific classesGroup Mat ClassesMat Class 5 Week Blocks are $60.00 and are for a specific 5 week period. Mat Class 10 Week Blocks are $110 and arefor a specific 10 week period. You must nominate a specific class time. No extensions will be given.To secure a position in the Lunchtime 30-minute Pilates classes, $7.50 must be paid in advance. Please be awarelunchtime Pilates classes are popular and paying in advance to secure your spot is highly recommended. If you do not want topay in advance to secure your place then please feel free to ring on the day and check availability.Lunchtime 30-minute Pilates memberships do not have an expiry date but if you book into a class and then cancel withoutgiving 24 hours notice or do not turn up, you will be charged for this class.Private Pilates, Equipment or Postural Assessment SessionsOne on one Pilates sessions are $80.00. Please give 24 hours notice if you wish to cancel an appointment otherwise youwill be charged the full amount for the session. We will endeavour to fill your appointment and if we succeed there willnot be a charge.Duo private sessions (for two people) are $80.00. If one person cannot attend the session, it is at the discretion of thetwo clients to either cancel the session 24 hours in advance or pay $40.00 each for the session regardless of attendance.The client attending can also choose to pay the full $80.00 for a private session.Group Equipment Based ClassesStudio Equipment 10 Class Blocks are valid for 12-weeks from purchase. Studio Equipment 5 Class Blocks are valid for6-weeks from purchase. No extensions will be given.Casual group equipment classes are payable in advance at $30.00 per session to secure a place. If you do not want topay in advance to secure your place then please feel free to ring on the day and check availability.Independent Pilates Studio UseIndependent studio memberships (5 or 10 classes) are valid for 6-months from purchase.Casual sessions for the studio are payable in advance or at the time of the session at $15.00 per session.Clients are asked to book a time to make sure of availability.There is no cancellation fee for these sessions but we would really appreciate if you could let us know when you areunable to attend your scheduled session.Please note:IOur classes have limited positions and regular waiting lists. No refund or make up sessions will be givenfor sessions purchased in a period and not used during the timeframe.have read and understood the Terms and Conditions above.SIGNED:(If under 16 must be signed by parent/guardian)DATE:____/____/_____Please include your email address so that we can notify you of any changes in our class schedules or when new classes start.………………………………………………………………………………