Client Registration Form


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2018

PAGE 1

NEW CLIENT REGISTRATION FORM ( HARA STUDIO COPY, OFFICE USE PLEASE PRINT )

FULL NAME ...................................................................................................... D.O.B ( OPTIONAL ) ........................................... ADDRESS

....................................................................................................................................................................................

........................................................................................................................................................................................................ PHONE ................................................ MOBILE .................................................. MAY WE SEND YOU TEXTS? : EMAIL ................................................................................................................. MAY WE SEND YOU EMAILS? : OCCUPATION PRIVATE

......................................................................

HEALTH

EMERGENCY

FUND

CONTACT

PHONE

(WORK)

Y Y

|

N

|

N

.....................................................................

........................................................................................................................................................

(NAME

&

PHONE)

......................................................................................................................

HOW DID YOU HEAR ABOUT THIS STUDIO? .................................................................................................................... 

FACEBOOK | 

INSTAGRAM | 

WORD OF MOUTH | 

POSTER | 

1. YOUR CURRENT INJURIES / ILLNESS / MEDICAL CONDITIONS? :

NEWSPAPER AD | 

( LAST 12 MONTHS )

WEB

......................................................

................................................................................................................................................................................................................... 2. YOUR PREVIOUS INJURIES / ILLNESS / MEDICAL CONDITIONS? : ................................................................................. ................................................................................................................................................................................................................... 3. YOUR PREVIOUS SURGERIES? : ................................................................................................................................................... 4. ANY MOVEMENT RESTRICTIONS? : ............................................................................................................................................. 5. ANY UNDIAGNOSED PAIN / WHERE? : ...................................................................................................................................... 6. HOW DOES YOUR MEDICAL CONDITION OR INJURY AFFECT YOU? : ........................................................................... ...................................................................................................................................................................................................................... 7. MEDICATIONS? : ............................................................................................................................................................................... 8. CURRENT TREATMENTS? : ............................................................................................................................................................. 9. ARE YOU PREGNANT?* : Y | N WHEN ARE YOU DUE? : .................................................................................................... *Please inform Hara Studio if you do become pregnant so we can modify exercises for you.

10. WHAT IS YOUR BABY AND BIRTH HISTORY? : .................................................................................................................... ................................................................................................................................................................................................................... 11. CURRENT EXERCISE REGIME / FREQUENCY? : .................................................................................................................... 12. MAY WE USE HANDS ON TECHNIQUES WITH YOU? : Y | N 13. MAY WE TAKE PHOTOS/VIDEO OF YOU FOR SOCIAL MEDIA? : Y | N

2/105 -107, WEST HIGH STREET, COFFS HARBOUR NSW AUSTRALIA

PHONE 02 66524462

BEYONDMOVEMENTSTUDIO.COM.AU

2018

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NEW CLIENT REGISTRATION FORM ( HARA STUDIO COPY ) Our studio respects your right to privacy. We realise that is important that you understand the purpose for which we collect details about your health, as well as how this information is used at our studio and to who it is disclosed. The policy of our studio is to follow these procedures: a) The information collected on this form will be used for the purpose of providing treatment to you. Personal information such as your name, address and health insurance details will be used for the purpose of addressing accounts to you as well as processing payments and writing to you about any issues affecting your treatment. Your email address will also added to our online newsletter and our online scheduling software. b) Your payment history, treatment records and other written materials relevant to your treatment will be kept here safely in a locked filing cabinet & on our software system. c) We may need to disclose your health information to your other health professionals if we feel it is necessary in the context of your treatment in this event please authorise your instructor to contact doctor/physiotherapist by phone or email to discuss your program and health concerns. Doctor / Physiotherapist : ........................................................................................................................................... Your health concerns? : ...............................................................................................................................................

I agree that the information I have given on this document is true and correct. I have read and understood all wording printed on this document and take full responsibility for my actions at any and all times on the premises of HARA beyond movement studio and during any workouts, classes, practice and use of equipment in any way whilst engaged in activities on the above premises or conducted by a trainer outside the premises. I agree to keep my instructor updated as to any changes in my medical profile and that there shall be no liability on the instructor if I fail to do so. I agree that neither I, my heirs, assigns or legal representatives will sue or make any other claims of any kind whatsoever against HARA Beyond Movement Studio its employees or its members for any personal injury, property damage/loss, or wrongful death, whether caused by negligence or otherwise. I agree that payments are non refundable and non transferable. I understand that I must give 48 hours notice for cancellations of studio/private/duo/trio sessions or the full fee will be charged. I am aware that all studio 10 blocks are strictly valid for 3 months. Class course blocks 10 & 20 are strictly valid per 10 week term only. Beginner & Therapeutic class 5 blocks are strictly valid for 5 weeks. Roaming class 5 blocks are strictly valid for 10 weeks. Workshops & holiday classes are valid for use only during the set dates. Pre booked group classes must be cancelled within 24 hours prior to class commencement, 2 cancelled classes (with notice) makeup per term only. If you are a NO SHOW to your booked class without cancelling prior you will be charged in full. No exchanges or refunds are given unless with a doctor’s certificate stating that you are unable to continue your training for medical reasons. In the case of vacations, we will hold your studio purchased blocks for no longer than 2 weeks per 3 month expiry. Exceptional emergency situations may be arranged separately. SIGNED : ...................................................................................................................... DATE : ...................................................... 2/105 -107, WEST HIGH STREET, COFFS HARBOUR NSW AUSTRALIA

PHONE 02 66524462

BEYONDMOVEMENTSTUDIO.COM.AU

2018

PAGE 3

NEW CLIENT REGISTRATION FORM ( YOUR COPY, PLEASE TAKE WITH YOU ) Our studio respects your right to privacy. We realise that is important that you understand the purpose for which we collect details about your health, as well as how this information is used at our studio and to who it is disclosed. The policy of our studio is to follow these procedures: a) The information collected on this form will be used for the purpose of providing treatment to you. Personal information such as your name, address and health insurance details will be used for the purpose of addressing accounts to you as well as processing payments and writing to you about any issues affecting your treatment. Your email address will also added to our online newsletter and our online scheduling software. b) Your payment history, treatment records and other written materials relevant to your treatment will be kept here safely in a locked filing cabinet & on our software system. c) We may need to disclose your health information to your other health professionals if we feel it is necessary in the context of your treatment in this event please authorise your instructor to contact doctor/physiotherapist by phone or email to discuss your program and health concerns. Doctor / Physiotherapist : ........................................................................................................................................... Your health concerns? : ...............................................................................................................................................

I agree that the information I have given on this document is true and correct. I have read and understood all wording printed on this document and take full responsibility for my actions at any and all times on the premises of HARA beyond movement studio and during any workouts, classes, practice and use of equipment in any way whilst engaged in activities on the above premises or conducted by a trainer outside the premises. I agree to keep my instructor updated as to any changes in my medical profile and that there shall be no liability on the instructor if I fail to do so. I agree that neither I, my heirs, assigns or legal representatives will sue or make any other claims of any kind whatsoever against HARA Beyond Movement Studio its employees or its members for any personal injury, property damage/loss, or wrongful death, whether caused by negligence or otherwise. I agree that payments are non refundable and non transferable. I understand that I must give 48 hours notice for cancellations of studio/private/duo/trio sessions or the full fee will be charged. I am aware that all studio 10 blocks are strictly valid for 3 months. Class course blocks 10 & 20 are strictly valid per 10 week term only. Beginner & Therapeutic class 5 blocks are strictly valid for 5 weeks. Roaming class 5 blocks are strictly valid for 10 weeks. Workshops & holiday classes are valid for use only during the set dates. Pre booked group classes must be cancelled within 24 hours prior to class commencement, 2 cancelled classes (with notice) makeup per term only. If you are a NO SHOW to your booked class without cancelling prior you will be charged in full. No exchanges or refunds are given unless with a doctor’s certificate stating that you are unable to continue your training for medical reasons. In the case of vacations, we will hold your studio purchased blocks for no longer than 2 weeks per 3 month expiry. Exceptional emergency situations may be arranged separately. SIGNED : ...................................................................................................................... DATE : ...................................................... 2/105 -107, WEST HIGH STREET, COFFS HARBOUR NSW AUSTRALIA

PHONE 02 66524462

BEYONDMOVEMENTSTUDIO.COM.AU