Welcome to KH Pilates

Referral:

Physiotherapist:

Chiropractor:

Doctor:

Other:

Emergency Contact:

Special Considerations- Do you suffer from any of the following?

Any Information provided remains private and confidential.

Heart problems; High blood pressure; Diabetes's/Hypoglycemia.

Fluid retention; light headedness/pots/fainting.

Asthma or shortness of breath; Epilepsy; Arthritis; Stroke; Recent Illness; infectious disease; hospitalization or surgery; Do you smoke? Allergies

Pregnancy; Medications; supplements; Other special considerations.

Have you done Reformer Pilates before if so where?

Are you achieving your health goals?

What is holding you back from achieving your goals?

How did you hear about KH Reformer Pilates?

Client Acknowledgement:

I have volunteered to participate in an exercise program under the direction of KH Pilates, which may include cardiovascular and/or resistance training exercises. I acknowledge and agree that I accept all risks associated with any and all activities and/or exercise in which I participate. I recognize that a full medical examination by a physician should be obtained prior to the commencement of any exercise program. If I have chosen not to obtain medical clearance prior to beginning a program I agree that I am doing so at my own risk.

I do here and forever release and hold harmless KH Pilates from any legal claims, demands, damages, rights or cases of action, present or future, arising out of or connected with my participation in this or any exercise program including any resulting injuries.

I hereby give KH Pilates permission to take pictures for social/promotion and community advertisements.

I understand that if I fail to cancel or reschedule my exercise appointment 24hours prior to the session time I may be held responsible for the payment of that session regardless of my attendance your text