This form requires acceptance of our client Terms & Conditions. Client registration - Mat Pilates 1 Personal details2 Background & Health3 Your aims4 Terms & conditions Name* First Last Address* Street Address City NSWNTACTQLDVICWASATAS State Postcode Home telephone*Mobile*Email* GenderMaleFemaleDOB (dd/MM/YYYY)OccupationEmergency contactsEmergency contact person* Emergency Phone*Relationship to youPhysician contact detailsPhysician Name* Surgery location Physician PhoneI give permission for the Pilates studio to contact my physician for any additional information they may require* Yes No Have you practiced Pilates previously?NoYesWhich type of pilates have you previously practiced?StudioMatBothWhere did you previously attend classes?Approx how many classes have you previously attended?1 - 1010 - 2020 or moreAre you or could you be pregnant now?NoYesPlease enter your expected due dateHave you had any previous pregnancies?YesNoHow was your baby delivered?NormalCaesareanForcepsIssues currently relating to your pregnancy?Do you have or have you suffered from the following conditions (please indicate): Diabetes High Blood Pressure Low Blood Pressure Heart Trouble Asthma Epilepsy Osteoporosis Arthritis Joint Replacement Neck Pain Back Pain Scoliosis Headaches/ Migraine Smoker Numbness/ Tingling Cancer Surgery Recent fracture Tendinitis Stress Anxiety Pinched nerve Hypermobile joints Major Accident Digestive Complaints Herniated Discs Bone/ Stress fracture Knee/ Hip Problems Shoulder/ Elbow/ Wrist Problems Foot/ankle problems (Orthotics) Long standing medical condition ie.Parkinsons, MS If you have selected any of the above conditions, please provide additional informationAre you currently taking any medications or medical treatments?NoYesPlease provide details of medications or medical treatmentsIs there any other information or conditions not listed above that your Pilates instructor should be aware of? What are your reasons for taking up Pilates? You will be charged a cancellation fee of one session if you do not provide Re:Align Pilates with one days notice of your absence. If you change your appointment for another time that week no charges will apply. The Pilates Mat Session you are undertaking is based upon sound teaching practice and information you have provided about yourself. You must therefore inform the studio/instructor of any changes to your medical conditions as soon as you become aware of them. If you experience any pain or dizziness during any class it is your responsibility to inform the instructor as soon as possible. All reasonable care is taken by Re:Align Pilates to ensure your safety, however you will take full responsibility for your actions in the studio. In the event of an emergency, you give permission for the studio to seek medical attention on your behalf. Re:Align Pilates accepts no liability for any injury or death relating to participation in Pilates unless caused directly from the negligence of one of the instructors. Confirmation* I confirm that I have read and understood the above conditions and that the information I have provided is correct PhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.