Registration form

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:*
- No medical concerns
- Muscle injury
- Spine injury
- Recent surgery
- Glaucoma
- Hernia
- High cholesterol
- High blood pressure
- Low blood pressure
- Rheumatoid arthritis
- Osteoarthritis
- Osteopenia
- Osteoporosis
- Diabetes
- Asthma
- Epilepsy
- Previous cancer
- Heart conditions
- Lung disease
- Recent child birth
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

FORMS

New clients registration
Antenatal Registration
Postnatal registration
Outcome measures

0203 764 5668

Angel Clinic
Business Design Centre
52 Upper Street
Angel
London
N1 0QH

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Bury Street Clinic
Revolution PT studios
Copenhagen House
5-10 Bury St
London
EC3A 5AT

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Chelsea Clinic
First Floor
321 Fulham Road
London
SW10 9QL

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© Copyright 2012 - | Designed and Maintained by WPMaintain | All Rights Reserved
Complete Pilates Medical Ltd registered in England & Wales at 115 Hampstead Road, London, NW1 3EE (for correspondence only), company number: 10206019.
Complete Physio Ltd registered in England & Wales. 18 Church Hill, Winchmore Hill, London, N21 2JB (for correspondence only), company number: 05926168

Registration form

General Information

Medical Information

General Information

Medical History

Females Only

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