New Client Intake Form
We look forward to working with you! Please complete form fully so we can create the safest, most effective program for you.
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Name *
Email Address: *
Date of Birth *
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DD
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Phone Number *
Street Address *
City, State *
Zip Code *
Emergency Contact Name *
Emergency Contact Phone Number *
Emergency Contact Relationship to you *
Do you have any current or old injuries, aches/pains, surgeries, etc.? *
Do you have any health concerns? - trouble breathing, high blood pressure, heart problems, diabetes, asthma, etc. *
Are you currently doing any therapy? - physical therapy, chiropractic care, massage, etc. *
What kinds of sports, exercise programs, and physical activities were or are you active? *
Do you have any previous experience with Pilates? If so, where? *
Describe what your typical day involves physically. *
What do you want most from Pilates? What are your physical goals? *
What day(s) would you prefer to schedule an appointment? *
Required
What time(s) of day works best for you? *
Required
By providing my initials, I am aware that photographs may be taken while I am in the studio for promotional use and will let instructor know if I prefer not to be photographed. *
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