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990 S Arroyo Pkwy Unit 2
Pasadena, CA, 91105
626-765-6500
Your Custom Text Here
Home
Studio Offerings
Physical Therapy/Massage/Nutrition
Physical Therapy
Massage
Nutrition
Pricing
Book a Mat Class
Our Story
Blog
Gallery
Polestar Certification Course + Continuing Education
Jobs
Location/Parking Info/Contact
Intake Form/Policies
Intake Form
Studio Policies
Intake Form, Policies, & Waiver of Liability
Participant Name
*
First Name
Last Name
Email Address
*
Birthday
*
MM
DD
YYYY
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Phone
*
(###)
###
####
Cell Phone
(###)
###
####
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone
*
(###)
###
####
Medical Conditions/Injuries
Physician's Name
*
First Name
Last Name
Physician's Phone
*
(###)
###
####
Do you exercise regularly?
How did you hear about Pilates of Pasadena?
Personal Goals
Number the following exercise benefits according to their importance to you ( 1 = most important, 10 = least)
Weight Loss
1
2
3
4
5
6
7
8
9
10
Weight Gain
1
2
3
4
5
6
7
8
9
10
Stress Reduction
1
2
3
4
5
6
7
8
9
10
Posture
1
2
3
4
5
6
7
8
9
10
Increase Flexibility
1
2
3
4
5
6
7
8
9
10
Increase Strength
1
2
3
4
5
6
7
8
9
10
Spinal Rehabilitation
1
2
3
4
5
6
7
8
9
10
Cardio Conditioning
1
2
3
4
5
6
7
8
9
10
Muscular-Skeletal Condition
Please list all injuries & surgeries. Check all body parts that are involved where appropriate.
Head
Arm
Hand
Cancer
Pelvis
Knee
Arthritis
Neck
Hip
Ankle
Bursitis
Shoulder
Leg
Foot
Osteoperosis
Wrist
Auto Immune
Breast Cancer
Mid Back
Low Back
Explain
Specify Right or Left. Please indicate the year of incident, and if physical therapy was performed.
Do you have painful or swollen joints?
Yes
No
Have you ever had a heart attack or stroke?
Yes
No
Do you suffer from any other following conditions?
Heart Disease
High/Low Blood Pressure
Breathing Difficulties (Asthma, Emphysema, etc.)
Headaches or Migraines
Dizziness
Diabetes
Do you smoke?
Yes
No
If yes, for how many years?
Are you pregnant?
Yes
No
If yes, when is your due date?
Have you had a C-Section?
Please describe any surgeries you have had in the last 5 years.
Please list all medications you are taking, and side-effects that might interfere with exercise.
List all previous and current physical activities and sports you engage in.
I will receive information and instruction while participating in the class, health program or workshop offered by Pilates of Pasadena LLC. I recognize that this class will require physical exertion, which may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved. 1. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in this class or any other activity associated with Pilates of Pasadena LLC. I represent and warrant that I am physically fit and have no medical conditions that would prevent my full participation in the class, health program or workshop. 2. I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I may incur as a result of participating in the program. 3. I knowingly, voluntarily and expressly waive any claim that I may have against Pilates of Pasadena LLC, instructors, employees, independent contractors, and Maria Jimenez for injuries or damages that I may sustain as a result of my participation. 4. Heirs, my legal representatives and I forever release and waive any liabilities against Pilates of Pasadena LLC, Maria Jimenez, and its instructors for any injury or death incurred by my voluntary participation in this class, workshop or activity. Purchase & Cancellation Policies • Advance payment is required to sign up for classes. Appointments can be made online, at the studio or by phone. • Please arrive on time for scheduled classes. Each selected scheduled 55-minute session will begin on time. If you are late, your training session will not be extended past the time it was originally scheduled to end. • No refunds on purchase of classes. Classes are transferable once purchased. • We require a 24 hour notice on any cancellations or no-shows. Otherwise, a class is subject to full charge. • A $25 fee is assessed for returned checks Studio Policies. • If you choose to wear shorts, we require that undergarment legging style shorts be worn. No shoes are allowed on the Pilates Studio floor. We have wipes available for your feet. If your feet are dirty, please wipe them before entering the exercise area. • The studio is an open space that is shared with other instructors and clients. Please be mindful of conversation level. • Please limit the amount of perfume/cologne you wear out of respect for others. • For safety reasons, do not start any part of your workout until your trainer is present. I HAVE READ THE ABOVE RELEASE AND WAIVER OF LIABILITY AND FULLY UNDERSTAND THEIR CONTENTS. I VOLUNTARILY AGREE TO THE TERMS AND CONDITIONS STATED ABOVE. By submitting this form, you acknowledge that you have read the above release and policies. Thank you so much for your time! See you in the studio!
First Name
Last Name
Date
MM
DD
YYYY
Thank you so much for your time. See you in the studio!
