PT Client intake form

PERSONAL TRAINING

Client Registration & Health Consent Form
Please select service:

Other
Personal Information
Name

First NameLast Name
Birth Date

MonthDayYear
Gender

Other
Contact Number

Area CodePhone number
E-mail
Address

Street Address

Street Address Line 2

CityState

Post CodeCountry
Occupation
Emergency Contact Name

First NameLast Name
Emergency Contact Number

Area CodePhone Number
The following information will provide me the information required to create the best possible training program and enviroment to suit your health and fitness needs.
Medical Information
Medical Checklist

Other
If you selected any of the above, please specify:
Do you have any current injuries?, please specify:
Have you ever followed an exercise program before? please specify:
When was the last time you exercised, please specify:
Do you have Private Health Insurance?
If yes, please record policy number
Policy Name/ Number
Please note; that I do not provide personal health insurance for clients, and you are responsible for checking that your own insurance provides appropriate cover for any injuries, medical treatment or related expenses arising from your participation in personal training.
Health & Fitness Goals
PAYMENT INFORMATION

Payments can be made by cash on arrival or by direct deposit into the following account:

BANK DETAILS

ACC Number: 078 844640

BSB: 105 - 135
_________________________________

PAYMENT OPTIONS

60min session

1 = $75 or 10 pack = $700

30min session

1 = $50 or 10 pack = $475
Confirmation and Consent

1) You hereby confirm to Zina Stone that, to the best of your knowledge, you do not have any physical, medical or other disability or condition which may be affected or aggravated by, or which may result in any sickness, injury or death to you as a result of, your inclusion in any Personal Training sessions.

2) You acknowledge that whilst every attempt is made to ensure that the training environment provided is safe, there are some significant and inherent risks involved, and you agree that you are participating voluntarily at your own risk and responsibility, thereby exposing yourself to certain risks.

3) You agree to make payment prior to commencing your first training session as per your training selection.

By acknowledging and signing below, I am delivering an electronic signature that will have the same effect as an original manual paper signature and be equally binding to the above statements.
Signature
Should be Empty:

PERSONAL TRAINING