01206 912422 
info@jpphysiopilates.co.uk 

Pilates Registration 

PILATES REGISTRATION FORM 

Please fill out the form below to register, and we will get back to you as soon as possible. 
General Client Details 
GP Details 
Pilates Aims 
What are the three main aims that you are hoping to achieve with Pilates? 
Lifestyle 
HEALTH QUESTIONNAIRE 
PILATES PARTICIPATION INFORMED CONSENT 
The Pilates program will begin at a low level and will be advanced in stages depending on your fitness level. We may stop the exercise session because of signs of fatigue or excessive strain. It is important for you to realise that you may stop when you wish because of feelings of fatigue or any other discomfort. 
 
There exists the possibility of certain dangers when exercising. They include abnormal blood pressure, fainting, irregular, fast or slow heart rhythm, and in rare instances, heart attack, stroke or death. Whilst every care will be taken, it is impossible to predict the body’s exact response to exercise. Every effort will be made to minimise these risks by evaluation of preliminary information relating to your health and fitness and by observations during exercising. Emergency equipment and trained personnel are available to deal with unusual situations that may arise. 
 
I understand that with certain conditions a degree of undressing may be required during the assessment, and that the Pilates instructor will explain this to me at the time. I understand that the Pilates program will be specifically designed as a personal training plan, and will take into account details given in my health questionnaire and assessment. Therefore, this program of exercise should only be undertaken when in a Pilates class, or when I have been given specific instructions to exercise on my own. 
 
Please note a full fee may be applicable if less than 24 hours notice is given for all cancellations. 
 
THIS INFORMATION IS PROTECTED BY THE DATA PROTECTION ACT 1984 
Jackie Parry 
Chartered Physiotherapist Grad Dip Phys HCPC 
APPI Pilates Instructor 
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