Online Intake Form – Mountain Life Pilates

Name *

First

Last

Today's Date *

Email *

Date of Birth *

Are you an Existing Client?

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone *

Emergency Contact *

First

Last

Emergency Contact's Phone *

What service are you looking for? *

With whom are you looking to schedule an appointment?

Which class would you like to register for? (All classes are 3 people max, and start Nov 23rd, for four weeks)

Medical History: Have you ever had, or do you currently have, any of the following? (check any that apply)

If so, please explain

Have you had Child/ren

Dates of Birth of Child/ren

Delivery

Have you ever had surgery? *

Please explain (date and procedure):

Do you have any current injuries? Please describe

What are your activity/exercise goals?

What do you hope to achieve through pilates?

What days/times work best for you for an appointment?

Would you like to be added to our mailing list to learn about new classes and other fun stuff? *