Pilates Health Questionnaire & Consent Form

Name *

First

Last

Address *

Address Line 1

City

State / Province / Region

Postal Code

Date of Birth *

Mobile No. *

Home Phone No.

Email *

Emergency Contact

Emergency Contact Name *

Relationship to you *

Phone *

GP Details

Name of GP (if known)

GP Practice *

GP Practice Address *

Address Line 1

City

State / Province / Region

Postal Code

Dear Participant,

The physical response to exercise varies and cannot always be predicted as every individual is different. While this class is designed for those with aches and pain in mind, it is not designed to treat your pain, specifically. If your pain flares up at any point during the course or you have any other injuries please let the instructor know immediately to allow them to adjust the exercises appropriately.

The Pilates programme will take into account details given in your health questionnaire to ensure your safety throughout; thus the exercises should only be undertaken in this class or when given instructions to exercise on your own. Each session should be seen as a building block for the next class, so you will likely gain the most benefit through full attendance of the course. If at any time you have questions regarding the exercises or the impact it has on your body, please do not hesitate to ask your instructor.

Most sessions will involve the opportunity to use various pieces of equipment, such as resistance bands. Whilst every effort is made to ensure the bands are in good condition, there is always the risk of the band(s) snapping during use and it is for this reason that I have to recommend the use of protective eyewear (glasses do not count) to protect your eyes during class. Protective eyewear is not provided as part of the class; should you wish to use this during class, you will need to bring your own.

As part of the class, pictures and videos are occasionally taken of participants exercising, by the Physiotherapist. Should you wish to opt out of any of these pictures or videos at the time that they are taken, you are very welcome to do so. You are also welcome to view these at the end of class and can request that any pictures or videos including you that you previously consented to, be deleted or taken down in future (where possible).

I agree to receive information about upcoming sessions and offers via email or text

I am happy to be included in videos and photos of the session(s) that will be uploaded publicly

Checkbox 1 *

I acknowledge that I have read the above and agree to notify the instructor if there are any changes in my life which might affect my participation or safety in a Pilates session.

Checkbox 2 *

I agree that the health information I have provided is accurate and complete to the best of my knowledge

Checkbox 3 *

I acknowledge that any attendance at subsequent sessions is taken as consent to that session.

Please click here to view our Privacy Policy.

Checkbox 4 *

I explicitly consent to the processing of personal and sensitive data I have included in this form and from any interactions with the therapist thereafter, in accordance with the therapist’s privacy policy

Signature *

Date *

Pilates Consent Form

Emergency Contact

GP Details

Health Details