Private classes Registerevent_titleevent_idName* First Last Email* Phone*Have you already completed a medical form with Core Pilates?*YesNoMedical HistoryGender*MaleFemaleDOB*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201. Do you have any injuies aches or pains? (recent or old)?*YesNo1. If yes, please specify*2. Are there any other health concerns?*YesNoeg. Astham, diabetes, high blood perssure, medication2. If yes, please specify*3. Are you presently doing any other kinds of therapy?*YesNoeg. massage, physio, chiropratic3. If yes, please specify*4. Are you or were you active in any sports, exercise programs, or physical activity?*YesNo4. If yes please specify*5. Have you had any past training in the pilates methods of movement?*YesNo5. If yes, please specify*Is there a possibility you could be pregnant?*YesNoWhat is your current occupation?*What does a typical day involve physically?*eg. sitting at at a computer, lifting, etcWhat are your goals?*eg. What do you want most from this program?I confirm that all information on this form is accurate* To the best of my knowledge PaymentI would like to register for*Please SelectWhole blockThis session onlySingle Session Price Price: £ 35.00 Block Session Price Price: £ 35.00 Coupon Total £ 0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20202021202220232024202520262027202820292030203120322033203420352036203720382039 Expiration Date Security Code Cardholder Name How did you hear about us*Please SelectReferralGoogle searchPrinted poster/flyerOtherTerms & Conditions* I confirm that I will not hold Core Pilates or anyone acting on it's behalf responsible for any injury incured whilst participating in either a class or private session run by Core Pilates Privacy* I confirm I am happy for Core Pilates to hold my personal details We will never sell or give away your details to anyone without your consent or knowledge.Please keep me up to date with core pilates This is to recieve uodates about upcoming classes and times Share this:PrintTwitterFacebookWhatsAppLinkedInLike this:Like Loading...
