Name *

First Name

Last Name

Birthday *

MM

DD

YYYY

Do you have any health or medical problems? E.g Heart Issues, asthma, high or low blood pressure, dizziness, chest pains, arthritis, osteoporosis, epilepsy, diabetes, etc, that we should know about? *

Yes

No

Do you have any pain of injuries/conditions (new or old) that may affect your movements in any way? *

Yes

No

Are you currently pregnant or have you recently given birth in the last 6 months? *

Yes

No

Do you take any medication that we should know about? *

Yes

No

Have you been referred by a health practitioner/medical professionals?

Yes

No

All the information given is true and correct and I have provided Platinum Studio Pilates with all the information about my health and wellness that may restrict my ability to perform a class. I have read and understood all wording and acknowledge it is my responsibility to inform Platinum Studio Pilates of any changes to the information given. I understand that Platinum Studio Pilates is completely absolved and unreservedly from any liability or legal proceedings resulting from acts of active passive negligence. I at all times reserve the right to stop at any time and am under no obligation to complete any programme that I do not feel is appropriate for me. *

Yes

I agree that my body is my responsibility and I will let my instructor know if I experience any pain or discomfort during the class. *

Yes

I acknowledge that if the instructor feels that I am unfit to participate in the workout, they will request that I discontinue the workout. *

Yes

I am aware of the Platinum Studio Pilates cancellation policy and agree to the terms and conditions of the use and access of their facilities. *

Yes