Consent Form – Life Ready Pilates Studio

Personal details
Title*
First name*
Last name*
Preferred name
Residential Address
Date of Birth*
Day
Month
Year
Phone
Email*
Do you have any medical conditions or injuries we need to know about?
What are your pilates goals?
Pilates goals*
Emergency Contact
Emergency Contact Name*
Emergency Contact Number*
Emergency Contact Relationship*
How did you hear about us
How did you hear about us?*
Your referrer's name?*
Your employer's name?*
Which online source?*
Please specify details*
Disclaimer
Liability waiver

Agreement for Participating in Pilates classes NB: This is a legal document that affects your rights – please read carefully. The 'trainer/therapist' refers to the Australian Registered Business ‘Life Ready Physio and Pilates Caulfield’ The 'activity' refers to the participation in Pilates classes, group strength, fitness and conditioning training and general advices. Before commencing exercise or changing your nutritional intake it's important to speak to your doctor and follow their recommendations. All programs are undertaken at your own risk - it is important to make responsible decisions for yourself.If you are undertaking any exercise and you feel pain, please alert the health professional.

I acknowledge that it is a condition of participating in this activity that I do so at my own risk:
- I accept all risks and hereby indemnify and release the physiotherapist, exercise physiologist, therapist, instructor, their agents, affiliates, employees, members, sponsors, promoters and any person or body directly and indirectly associated with the Trainer/Therapist, against all liability (including liability for their negligence and the negligence of others) claims, demands, and proceedings arising out of or connected with my participation in this activity
- This release and indemnity continues forever and binds my heirs, successors, executors, personal representatives and assigns
- I acknowledge that participating in this activity may involve a risk of serious injury or even death from various causes including: overexertion, dehydration, equipment failure and accidents with equipment and surroundings
- I recognise the difficulties associated with the activity and attest I am physically fit to participate safely in the activity and that a qualified medical practitioner has not advised me otherwise.
- I understand the demanding physical nature of this activity. I am not aware of any medical condition, injury or impairment that will be detrimental to my health if I participate in this activity. In the event that I become aware of any medical condition, injury or impairment that may be detrimental to my health if I participate in this activity my Trainer will be immediately informed. By continuing to participate in this activity I accept the risks despite these conditions and am still, and will always be under the terms of this agreement.
Consent*
I have completed my medical history details to the best of my ability and have read and understood the risks associated with treatment. I give consent to receive any or all of the treatments outlined above at Life Ready Physio + Pilates and acknowledge that I am entitled to ask for further information at any time.
Communication request
Most of our communications like appointment reminders, check-ins, request for feedback and clinic specials are done through email and/or SMS. Please tick if you DO NOT wish to receive SMS correspondence (this includes appointment reminders). You can request an opt-out from our team at any stage
Signature*

Personal details

What are your pilates goals?

Emergency Contact

How did you hear about us

Disclaimer

Liability waiver