Section One

As Chartered Physiotherapists our Pilates instructors have a legal obligation to collect and process the information asked in section 1 to comply with the requirements of their professional registration and therefore we do not require your consent for the first section of this form. Where information to be supplied is voluntary or where we do need consent this is identified. The information provided will be uploaded onto our secure software database and used for the purpose of maintaining appropriate contact details and for your own safety and well-being.

Prescribed Pilates is Physiotherapy led. Our Physiotherapists can modify any exercise to help to address any medical issues or pain that you may have. Our Pilates can simply be a form of exercise or as a method of managing a health problem. If you do have an active injury or medical problem then we strongly suggest a 1:1 session to assess this thoroughly. You must declare below any problems that you have had in the past or that you are currently experiencing problems with so that we can make the necessary adjustments within the class.

Have you had heart trouble or a heart defect?Have you ever had pain in the chest when you undertake physical activity?Do you suffer from regular headaches?Have you ever lost balance because of dizziness?Have you ever lost consciousness or regularly felt faint or dizzy?Do you suffer from either high or low blood pressure?Have you had any major surgery in the last 10 years?Have you had any minor surgery in the last two years?Do you have asthma, diabetes or epilepsy?Are you taking any regular medications?Have you been pregnant in the past six months, or are you pregnant now?

Osteoarthritis?Rheumatoid arthritis?Osteoporosis or Osteopenia?Hypermobility Syndrome? (excessively flexible joints)Any other bone or joint problem?Any other muscular problem?Any other condition?

Please use the space below to give details of any of the above, stating how they may affect your ability to exercise.

Section two:

The following information is voluntary and you do not have to complete it. However, we have a legitimate interest in requesting this data and we believe it will assist in providing the best treatment to you.

YesNo

Pilates can improve pain caused by repetitive and poor postures. For us to understand what could influence your posture please answer the following:

Consent to Pilates at KTB
• I confirm the information I have given is accurate and hereby give consent to receiving Pilates based physiotherapy from KTB Rehabilitation on this and any subsequent occasion.
• I understand that the classes will always be taken by a Chartered State Registered Physiotherapist.
• I understand that it is my responsibility to inform the Physiotherapist taking my class of any change in my medical or health status and also of any pain or discomfort experienced during a class.
• I understand that a 1:1 session is recommended before joining a class to fully discuss and assess any medical, joint or muscular problem that I have disclosed. I understand that my medical history will be treated with the strictest of confidence.

Private Patients Self Funding their Appointments/Pilates
• I have been advised of the current fees charged by the centre at each clinic and understand the payment terms.
• I agree to pay at the time of booking each appointment.

Non Attendance Policies
• Over 24 hours notice to cancel - no charge
• Less than 24 hours notice to cancel - £15 fee 30 min appt; £30 60 min appt
• Less than 24 hours notice on more than two occasions - full fee

Prescribed Pilates Classes
• Our Pilates classes are paid for in advance for a six week course. You will reserve a place on a set session and will be expected on that session each week from the date that you pay.
• Allow 24hrs cancellation notice. We do have a flexible policy whereby if you are unable to attend your booked session you can inform reception and change this class to another time within your six weeks according to availability.

I have read and understood the non attendance policy and privacy policy for KTB. Any questions that I raised were answered to my satisfaction by a member of KTBs administration team. As required by data protection we have a duty to inform you that you can withdraw your consent for any of the permissions detailed below at any time. Should you wish to withdraw consent please discuss this with a member of staff in the first instance.

Signed: