Bookings Essential Client Manager

Emergency Contact Name^*

Emergency Contact Number^*

Back, neck or joint pain^*

YesNo

Recent injury and surgery^*

YesNo

Pelvic floor dysfunction or prolapse^*

YesNo

Abdominal separation (diastasis recti)^*

YesNo

Cardiovascular condition^*

YesNo

Neurological condition^*

YesNo

Respiratory condition^*

YesNo

Chronic pain^*

YesNo

Osteoporosis or bone density issues^*

YesNo

Other medical condition (please specifiy)

Are you pregnant?^*

YesNo

Are you postpartum?^*

YesNo

If postpartum, how many weeks?

If you are less than 12 week postpartum, do you confirm that you have been cleared by your medical practitioner (e.g. GP, obstetrician, women’s health physiotherapist) to participate in exercise, including Pilates.

YesNo

Name of Practitioner (optional)

Please list any injuries, surgeries, or current treatments (including physiotherapy or allied health care).

I understand that Pilates instruction may include verbal, visual, and tactile (hands-on) cues to assist with technique and safety.^*

YesNo

I consent to the use of tactile cues.^*

YesNo

I declare that:

The information that I have provided is true and complete to the best of my knowledge.
I will inform Gem Pilates Studio of any changes to my health and medical status.
I understand that Pilates is a physcial activity and carries inherent risks.
I acknowledge that instructors are not medical professionals and Pilates is not a substitute for medical advice or treatment.
If I am less than 12 weeks postpartum, I confirm that I have been cleared by a qualified medical practitioner to participate in exercise.
I agree to participate in classes at my own risk, subject to my rights under the Australian Consumer Law.
I understand that cancellations must be made at least 24 hours in advance to avoid forfeiting my class, in accordance with studio terms of service.

YesNo

Date of Acknowledgement^*

Email:*

Title:*
First Name:*
Last Name:*
Date of Birth:*
Mobile No.:*
Work No.:
Home No.:
Address 1:*
Address 2:
Suburb:*
State:*
Postcode:*

Password:*
Confirm Password:*
Password at least 8 characters and contain at least 1 number

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