GRAVITY Studio
Please fill out this brief health questionnaire to help us ensure your safety while participating in GRAVITY Studio classes.
Do you have any significant past medical history that we should know about, including any prior orthopedic injuries, illnesses, hospitalizations, or surgeries?
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Area(s) of the body that you have pain, weakness, or dysfunction:
Low Back/Mid Back/Neck
Hip/Knee/Ankle
Shoulder/Elbow/Hand/Wrist
Other: ________________________________
Please describe in detail: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Medications you are currently taking: ______________________________________________________________________________________
Do you smoke or use tobacco products? Y/N
Occupation: _____________________________________________________________
Desk Job? Y/N Prolonged Sitting/Standing? Y/N Lifting? Y/N
Are you pregnant? Y/N Due Date __________ OB-GYN _______________________
I, the undersigned, assume all responsibility for and all risk of damage or injury that may occur as a result of my own actions, inactions, or negligence, or that of others as a client of Ascent Therapy Clinics and Wellness Centers. In consideration of and as a part of payment for the right to participate in GRAVITY studio classes or Pilates lessons, I will hold harmless and release and discharge all rights and claims for damages that I may have or that may hereafter accrue to me against Ascent Therapy Clinics and Wellness Centers, its owners, employees, and agents for and all injuries resulting from or arising out of, or incident to, my use of an Ascent studio. The terms hereof shall serve as a release, indemnification, and assumption of risk for my heirs, executors, administrators, and for all members of my family.
I have read, understand, and signed the foregoing assumption of risk and release of liability agreement.
Signature:______________________________________________________________
Date:__________________________________________________________________
Ascent Therapy Clinics and Wellness Centers
Name:_______________________________________ Date:_________
Street Address:______________________________________________
City:______________________ State:_______ Zip:________________
Email Address:____________________ Age:________ DOB:________
Home Phone:_________________ Work/Cell Phone:_______________
In Case of Emergency, Please Call: _____________________________
Phone:_____________________ Relationship:_____________________
How did you hear about Ascent Therapy Clinics and Wellness Centers?
___________________________________________________________
Staff Use Only
Staff Initial:_____________________________ Client #:_____________
Classes Registering For (Circle One): *GRAVITY 2x week *GRAVITY 3x week
*I.W.P. *PILATES Private *PILATES Group Mat *Group 5/10 pack
*Private 5/10 pack
Class Days/ Times:____________________________________________
Start Date:______________________ End Date:____________________
*Start Date begins on day of first paid class * End Date is 14 weeks after start date
Method of Payment (Circle One): Visa, MasterCard, Cash, Check
Discounts/ Promotions:_________________________________________
Total Amount Owed:_________________ Total Paid Today:___________
Payment Plan Dates/ Amounts:___________________________________
Payments are non-refundable and non-transferable. Payment is due at the time of service. By signing below you are agreeing to the terms stated above. All fourteen-week sessions are non-negotiable and payment is due in full or in three monthly installments with an extended billing fee. By signing below the client agrees and acknowledges that he or she is ultimately responsible for the payment of all services rendered.
Client Signature:______________________________________ Date:________________