Client Health Form

Name

First Name

Last Name

Phone

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact

First Name

Last Name

Emergency Contact Phone

(###)

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List Past / Current Medical History

List any allergies or medications you are taking

List any medical professionals you are currently seeing

List any other information that might be helpful for us to know

POLICY:

I understand that a 24-hour notice must be given when canceling scheduled appointments. If I do not cancel 24+ hours in advance, I will be responsible for 100% of the cost of the service. I understand that all sales are final. There are no refunds for paid service (including cancellation charges). I have agreed to participate in a program of progressive physical exercise. The exercise program includes cardiovascular conditioning, muscle strength, endurance and flexibility work. The possible benefits of this exercise program include: improving cardiovascular fitness, muscle strength, endurance, flexibility, body posture and alignment. I recognize that exercise carries some risk to the musculoskeletal system and the cardiorespiratory system. The possibility of certain unusual changes during exercise does exist. They include such conditions as muscle soreness or stiffness, abnormal blood pressure, fainting, disorders or heartbeat and instances of heart attack and death. I hereby acknowledge and accept these risks. To my knowledge, I do not have any limiting physical conditions or disability that would prelude an exercise program. I hereby certify that I know of no medical problem (except those noted above) that would increase my risk of illness and injury as a result of participation in a regular exercise program I waive, indemnify, exonerate, hold harmless Stephanie Bittner and assigns for any claims, demands and causes of action (including attorney’s fees) arising out of or pertaining to any loss, damage, injury or death sustained, caused by any negligent act or act of omission or my participation in the program designed by Stephanie Bittner or breach of duty related to Stephanie Bittner. This release applies whether or not any claim, demand, action or suite is based upon or alleged to be based on or in part, the negligent act or act of omission or similar conduct of those parties are hereby released and indemnified. I do hereby assume all risk and hazards in volunteering to participate in this fitness program. I hereby acknowledge that I possess adequate medical and hospitalization insurance coverage in case of injury. I further acknowledge that I might have the right to choose what exercises I do or do not perform in addition to withdrawing from any exercise at any time. I ACKNOWLEDGE THAT I HAVE CAREFULLY READ THIS CONSENT AND FULLY UNDERSTAND THAT IT IS A RELEASE OF ALL LIABILITY. IN ADDITION, I DO HEREBY WAIVE ANY RIGHT THAT I MAY HAVE TO BRING A LEGAL ACTION OR ASSERT A CLAIM FOR INJURY OR LOSS OF ANY KIND AGAINST ME FOR MY NEGLIGENCE OR ARISING OUT OF OR RELATING TO PARTICIPATION BY ME IN ANY OF THE ACTIVITIES, OR USE OF ANY EQUIPMENT, FACILITIES OR SERVICES PROVIDED. Initial below to agree to the above policy

Click below to confirm the above policy

I agree

Client Health Form

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