New client registration form - Complete Pilates

General Information

Name*

First Last

Address*

Street address Address line City Postcode Country

Date of Birth*

DD

MM

YYYY

Sex*

Male
Female
Would rather not say

Telephone Number*

Email*

How did you hear about Complete Pilates?*

Medical Information

Do you have Private Medical Insurance?

Yes
No

Provider

Policy Number

Authorisation Number

GP Name

GP Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Have you been referred by someone?

Yes
No

Please let us know who

Rehabilitation Goals

Other (please specify)

Are you currently on any medication?

Yes
No

General Information

Occupation*

Activity levels within the last 2 years (type, frequency, duration)*

Have you previously participated in Pilates?*

Yes
No

Please give detail

Medical History

Do you have a history of or are you currently experiencing any of the following:*

Other (please specify)

Females Only

Are you pregnant or have you been pregnant within the last 6 months?

Yes
No

How many weeks?

Due Date

Do you have any pregnancy related conditions? (If yes please specify and detail whether you have consulted a Doctor):

Have you ever had a C-Section?

Yes
No

Please date

Have you ever received clinical treatment or rehabilitation for a pregnancy related injury?

Yes
No

Please specify

Please accept the below policies*

I have read the terms and conditions
I understand the cancellation policy
I understand the privacy Policy

Registration form

General Information

Medical Information

General Information

Medical History

Females Only

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