FREQ MODE

Client Waiver

First name

Last name

Phone

Birthday

Day

Month

Year

Have you practiced Reformer Pilates before?

Yes - beginner

Yes - advanced

Yes - mat Pilates only

Are you pregnant or trying to become pregnant?

Yes - pregnant

Yes - trying

Do you have any medical or metal implants?

Yes

Are you taking medication which may effect you during the session?

Yes

Do you have or been diagnosed with any of the following: - Epilepsy or seizures - Metal Implant - Diabetes - Rheumatoid arthritis - Blood disorder - Asthma - Heart Condition - Pacemaker - High/low blood pressure - Other (if so, please provide details)

Do you have any illness, Disabilities, injuries, joint problems, recent surgery, any other condition/reason that you should not participate in physical activity without medical supervision? (if so, please provide details)

Waiver

I verify that all information is correct and current to the best of my knowledge. I understand that any information provided is for safety purposes and will be kept strictly confidential, unless I provide written consent. I hereby give my consent to participate and I acknowledge and agree that I am doing so at my own risk.

My health and safety with respect to such services are my sole responsibility. My decision to participate is voluntary, and I know of, understand and assume any and all the risks associated therewith.

In exchange for receiving services for myself and on behalf of my heirs, executors, administrators and personal representatives, hereby waive, release, discharge and hold Sally Heinjus and the location harmless from any and all liability for any and all injuries, including damages or claims relating to or resulting from my receipt of the services, now or in the future, foreseen or unforeseen.

If I experience pain or discomfort during the session, I will immediately inform Sally Heinjus, and/or quietly remove myself from the room. I will not hold Sally Heinjus responsible for any pain or discomfort I experience before, during or after the session.

I affirm that I have notified Sally Heinjus of all known medical conditions and injuries. I agree to inform Sally Heinjus of any changes in my health and medical condition. I understand that there shall be no liability on Sally Heinjus's part should I forget to do so.

By signing below, I acknowledge and agree that:

I have voluntarily chosen to participate in the Freq Mode by Sally Heinjus.

I have read, understood, and agree to the Terms and Conditions

I release and discharge Sally Heinjus from any liability, claims, demands, or causes of action arising from my participation, past, present and future relating to this treatment except where prohibited by law.

I confirm that all information provided on this form is true and complete to the best of my knowledge.

Signature

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