Registration form

General Information
Name*
First Last
Address*
Street address Address line City Postcode Country
Date of Birth*

Day
Month
Year
Sex*
- Male
- Female
- Would rather not say
Telephone Number*
Email*
How did you hear about Complete Pilates?*
Medical Information
Hidden
Do you have Private Medical Insurance?
- Yes
- No
Hidden
Provider
Hidden
Policy Number
Hidden
Authorisation Number
Hidden
GP Name
Hidden
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
Oncology rehabilitation registration

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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