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Home
Video Subscription
About Us
Privates & Semi Privates
Instructors
Forms & Waivers
Policies & Procedures
Classes
Class Info
Class Schedule
Prices
Blog
Contact
Intake Form & Waiver
Below are our health intake form and liability waiver. Please fill out both and submit before your first visit. You may also download and print the forms to bring with you.
Health Intake Form
Open Form
New Form
Name
*
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Email Address
*
How did you hear about us?
*
Birthday
MM
DD
YYYY
GOALS: What would you like to focus on?
Flexibility
Pain Reduction
Rehabilitation
Stress Management
Weight Loss
Endurance
Strength
Sport Specific Training/Conditioning
Please describe more specifically:
*
Anything else you'd like us to know about your goals?
Exercise Background: How often do you exercise & how long are your sessions?
*
What type of exercise do you like?
*
How would you describe your current condition ?
What level of intensity do you exercise typically?
Very Light
Light
Moderate
Heavy
How often do you plan to practice Pilates? (We recommend at least twice a week).
Health History: Please check if you have a history of any of the following.
Lower Back Issues
Upper Back Issues
Sciatica
Tendon/Ligament/Muscle Strain
Shoulder Issues
Disc Issues
Heart/Circulatory Disorders
High/Low Blood Pressure
Diabetes
Leg Length Discrepancy
Foot Issues
Scoliosis
Hip Issues/Replacement
Ankle Issues
Neck Problems
Joint replacement
Shoulder dislocation
Arthritis
Numbness/Tingling
Osteoporosis
Seizures
Cancer
Musculoskeletal Issues
Abdominal Surgery
Cesarean Section
Headaches
Vertigo/Dizziness
Nerological (MS, Parkinsons)
Please describe in more detail any conditions above. Include any surgeries we should know about, dates, severity, and treatments.
Are you under any medical restrictions?If yes, please describe.
Are you taking any medications? If yes, please list.
Are you pregnant? If yes, please give due date and current month.
Thank you!
Cancellation Policy & Liability Waiver
Open Form
Cancellation Policy & Liability Waiver
Cancellation Policy
*
I understand there is a 24-hour cancellation policy for all previously reserved private, and semi-privates and a 24-hour cancellation policy for group classes. Please contact your instructor within 24 hours so we may release your appointment time or go online to cancel your class spot to allow another client to attend. Otherwise we will need to charge you in full for the session or class.
Agree
Disagree
ACKNOWLEDGEMENT OF RISK AND WAIVER LIABILITY
*
I understand that I will be participating in a fitness program at Pilates Durango that will require physical exertion. Before beginning the program I was asked by the instructor if I had any physical limitations, or whether I am taking any medication or receiving any medical treatment that might make it unsafe for me to participate in the fitness program. There is no such limitation, medication or medical treatment other than those I have disclosed on the attached sheet. I understand that by signing this statement I am agreeing to the Pilates Durango Cancellation Policy. I am also agreeing to not hold Pilates Durango and its business owners, Rhonda Unkovskoy (Pilates Dynamic) Marisa Haga (Marisa Haga,LLC) and contractors Lori Moore (Prime Pilates LLC), Priscilla Blevins (Priscilla Blevins LLC) Lori Van Atta, Hannah Gerres (In Play Pilates LLC), Val Russel (Push Pilates LLC), K-Lea Gifford, and any other employees, agents or insurers responsible for any bodily injury or property damage that I may suffer as a result of my participation in a fitness program through Pilates Durango.
Agree
Disagree
Name
*
First Name
Last Name
Email Address
*
Thank you!
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