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FLEXIBILITY. STRENGTH. ENDURANCE

THE NUMBER 1 PILATES

STUDIO IN MIAMI

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Medical Questionnaire

Please fill out the following form to help us understand your physical condition.

First name

Email Address

Last name

Date of Birth

Have you been hospitalized in the last 12 months? *

Yes

Are you currently suffering from a medical condition, illness, or injury? *

Yes

If you answered yes to any question, please elaborate

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

Gym Health Waiver

To register to our gym please fill out the following medical form

First name

Email Address

Last name

Date of Birth

Do you have a doctor’s permit to participate in intense physical activities? *

Yes

Have you lost your consciousness in the last past 12 months? *

Yes

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

The best giftcard

‏25 ‏$

You can't go wrong with a gift card. Choose an amount and write a personalized message to make this gift your own.

Amount

‏25 ‏$

‏50 ‏$

‏100 ‏$

‏150 ‏$

‏200 ‏$

Quantity

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Contact us

500 Terry Francois St.

San Francisco, CA, 94158

info@mysite.com

Tel: 123-456-7890

Find us

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