"*" indicates required fields BODY BALANCE INSTITUTEClient HistoryToday's Date* MM slash DD slash YYYY Name* First DOB*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender* Male Female Address* Street Address City State / Province / Region ZIP / Postal Code Home Phone*Cell PhoneWork PhoneEmail Address* Occupation*Height*Weight*This field is hidden when viewing the formHow Did You Hear About Us? A Friend Internet Print Ad Other How Did You Hear About Us?* A Friend Internet Print Ad Other Previous experience with Pilates, Gyrotonic, Massage Therapy or Nutrition? Please explain:*Are you currently engaged in other types of activities or sports? Please explain:*Are you aware of any physical limitations of exclusions of certain activities? Please explain:*Have you currently or ever been diagnosed with any of the following?* Arthritis Back Pain Fibromyalgia Disc Problems Neck or Cervical Pain Heart Disease Hypo or Hyperglycemia High Blood Pressure Osteoporosis or Osteopenia Seizure Disorder Arrhythmias Numbness Low Blood Pressure Diabetes Vertigo Other Please list past and recent surgeries:*Is there anything else that you feel we should know about and have not asked? (i.e. pregnancy, other) Please explain:*Personal fitness goals:* Improve strength Improve flexibility Injury prevention Change current body composition Learn better eating habits Stress management Sport specific improvement Other Agreement of Release and Waiver of LiabilityThis field is hidden when viewing the formUser Name* First I, hereby agree to the following: I am a participant in the fitness, massage, and/or nutrition program offered by Body Balance Institute, LLC (herein referred to as BBI) during which I will receive information and instruction about exercise, massage, and/or nutrition. I recognize that fitness programs require physical exertion which may be strenuous and could cause physical injury, and I am fully aware of the risks and hazards involved. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the health, fitness, nutrition, and/or massage programs offered through BBI. I represent and warrant that I have no medical condition or that I have disclosed all previous or current injuries or illnesses that would impact my full participation in the fitness, nutrition, and massage programs offered through BBI. In consideration of my participation in BBI fitness, nutrition, and/or massage programs, classes, or consultation, I knowingly, voluntarily and expressly waive any claim I may have against Vicki Sullivan, BBI or its employees for injury or damages that I may sustain as a result of participating in the program. I hereby affirm that I have read and fully understand the above waiver of liability. I voluntarily agree to the terms and conditions stated above. AGREEMENT TO THE TERMS AND CONDITIONS I agree and understand that it is my responsibility to give 24 hour notice in the event that I cannot fulfill my appointment, and I understand that I will be charged for one full session if I fail to give proper notice. Signature*Date* MM slash DD slash YYYY This field is hidden when viewing the formGuardian Name* First As Legal Guardian of , I consent to the above terms and conditions Signature of Guardian*Date* MM slash DD slash YYYY BODY BALANCE INSTITUTEPOLICIES & PROCEDURESToday's Date* MM slash DD slash YYYY We look forward to helping you achieve your health and fitness goals. In order to best serve you, we have adopted the following policies and procedures. Please sign your initials next to each policy to ensure that you and Body Balance Institute are in agreement. Appointments Payment for services is due at the time of your appointment. Please observe our (24) hour cancellation policy. This applies to all of our sessions and classes. Clients who cancel in less than (24) hours are responsible for the full amount of that session. All sessions are (55) minutes unless otherwise scheduled. Appointments will not be extended to accommodate late arrivals Missing a regular appointment or class more than (2) times (unless special arrangements are made) will result in loss of that reserved time. We do not offer refunds, however transfers of credit can be arranged. All pre-paid sessions expire after (1) year from the date of purchase. ‘No shows’ for appointments and classes will be charged the full amount of that appointment or class. Shared Sessions (Duets & Trios): Clients who are sharing an appointment (duets and trios) are responsible for communicating with their partner regarding the following: Deciding on and booking a standing appointment. Giving the studio and the other client (24) hours notice if a session must be canceled or rescheduled In the event that one person cancels, the other client may keep the appointment. The person who cancels is responsible to pay for their half of the shared session. The appointment will be treated as a private session only if each partner has an individual session package. Classes To attend a class, students must have completed three private sessions and receive instructor permission. Due to small class sizes, clients must call ahead to reserve a spot in class, or must purchase a class series of (4) or (8). Series packages must be used consecutively, so please plan to attend each class. Students are allowed (1) make-up class per series. Body Balance Institute reserves the right to cancel classes due to low attendance. Prices and class schedules are subject to change without notice.
