Intake Form & WaiverIf this is your first time working with me, please fill out the intake form and waiver below before your first session. Name * First Name Last Name Date of birth * MM DD YYYY Phone * (###) ### #### Email * Address * Emergency Contact Name * Emergency Contact Number * Will this be your first time doing Pilates? * What are your health and fitness goals? * What activities and/or sports have you practiced in the past? How often? * What physical activities or sports do you currently practice? How often? * Describe any and all physical injuries, surgeries or discomfort * What brings you to Pilates? * Select all that apply Overall Fitness/Flexibility Pre/Postnatal Pain Relief Injury Recovery Are you currently in pain? * Yes No What services are you interested in? * Private Sessions Semiprivates Group Classes Virtual Sessions On Demand Videos Are you currently pregnant? (women only) Yes No If yes, please enter due date. (women only) Have you ever been pregnant before? How many births? (women only) If you have been pregnant before, did you experience any of the following? (women only) Cesarean section Abdominal separation Episiotomy How did you hear about me? * Google Search Yelp Social Media Referral Who may I thank you for referring you to my practice? * TERMS & CONDITIONS LIABILITY WAIVER * In consideration for being allowed to participate in the activities and programs offered by Pilates instructor Clarissa Smirnov at any given facility, to use equipment and props in addition to the payments of any fees and charges, I do hereby waive, release, and forever discharge Clarissa Smirnov and the facility where classes and sessions are held from any and all responsibilities or liability from injuries or damages resulting from my participation in the above mentioned activities. I understand and am aware that exercise is a potentially hazardous activity. I also understand that fitness activities involve risk of injury and even death, and I am voluntarily participating in these activities and using equipment and machinery with knowledge of the dangers involved. I expressly assume and accept all risks. I hereby release and agree to hold Clarissa Smirnov and the facility where classes and sessions are held harmless from any causes of action, claims, demands, damages, costs, expenses and compensation for damage to myself that may be caused by any act, or failure to act, or that may otherwise arise in any way with any services received. I understand that this release discharges the aforementioned from any liability with respect to bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received. This liability waiver and release extends to all owners, partners and employees. MEDICAL CLEARANCE – We recommend you consult with a physician before starting this or any exercise program. If you experience any pain or discomfort during the course of the program, stop exercising immediately and seek medical attention. Pre natal and post natal clients must consult with their physician and have received verbal clearance to perform physical exercise. TERMS & CONDITIONS – All sessions and classes are 50 minutes in length. Private sessions require a cancelation notice that is received by e-mail or via the online scheduler within 24 hours from the appointment time. Group classes require a 48-hour cancelation notice. If you do not show or do not cancel or reschedule your class/session within the cancelation period, you will be charged the full rate. All sessions and packages are non-transferrable and non-refundable. Packages and unused sessions are valid for 90 days from the date of purchase. COVID-19 DISCLAIMER – I acknowledge that Clarissa Smirnov and all practitioners at the facility where services are rendered adhere to the CDC recommendations of preventative measures to reduce the spread of the COVID-19 virus to the best of their abilities, including but not limited to social distancing, face coverings and disinfecting. I acknowledge the contagious nature of the COVID-19 virus and that no guarantee exists regarding whether or not I may contract COVID-19. I understand that the risk of becoming exposed to and/or infected by the COVID-19 virus may result from the actions, omissions, or negligence of myself and others, including, but not limited to, staff and other clients. I acknowledge that I increase my risk of exposure to COVID-19 by participating in services rendered. I acknowledge that I must comply with all set procedures to reduce the spread while in attendance. ELECTRONIC SIGNATURE CONSENT – By checking below, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use electronic signature with Clarissa Smirnov for any documents will continue until such time you notify us in writing that you no longer wish to use an electronic signature. There’s no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary. I have read and agree to the terms and conditions. Thank you!
