Pilates Form | Julie Carolan Physical Therapy & Pilates

Name *

First

Last

Address *

Age *

Telephone Number *

Occupation

Do you have any health issues or injuries *

If you answered Yes to the previous question, please give details.

Are you currently taking any medication? *

If you answered Yes to the previous question, please give details.

Do you engage in regular exercise? *

If you answered Yes to the previous question, please give details.

Are you pregnant or have you been in the last 6 months? *

Have you taken part in a Pilates Class before?

I have highlighted on this form any medical condition that might affect my ability to partake in this Pilates class. I have disclosed all health issues and medications and have consulted with my GP (where necessary) in order to partake in this class. I understand that I take part in this class at my own risk. Please tick the box to confirm your agreement. *

Agree

By providing the information you have submitted, you consent to the collection and storage of your data as described in the privacy policy, which is available for inspection on request. Please tick the box to confirm your agreement. *

Agree