First name
Last name
Email
Phone
What is your age range?
18 - 29
30 - 40
41 - 49
50 and above
Do you have any of the following conditions that your instructor should be aware of?
Asthma
Pregnancy
Heart/ Circulatory problems
Dizzy spells/Fainting
High Blood Pressure/ Sugar
Epilepsy/Seizures
Joint / Muscular injury (Neck/Back/Spine, hip, knee)
Low Blood Pressure/ Sugar
Other
Recent Surgery? If yes, please specify
Yes
No
Preferred Service
Yoga
Pilates
Barre
Dance/ Aerobics
Massage Therapy
Wellness & Nutrition Coaching
Rehabilitation
Where would you like to have your sessions?
Online
In person
If you chose in person sessions, please select location
At the studio
In your home
Other
What is your preferred time to have sessions?
Early mornings - 6 - 9 am
Late Mornings (10 am - 12pm)
Afternoons (1pm - 4pm)
Evenings (5pm - 8pm)
Flexible
How often would you want to practice?
Once a week
Twice a week
3 times a week
Other
Have you practiced any of the above activities before?
Yes
No
If yes, please specify.
Current Fitness Level
Beginner
Intermediate
Advanced
What are your fitness / wellness goals? Please list below
What day are you looking to start?
Month
Day
Year
How did you hear about us?
Google
Social media
Friend / Family
Other
Submit
CLIENT INTAKE FORM