ONLINE FORM – NB Performance

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Emergency Contact Name

Emergency Contact Phone Number

Emergency Contact Relationship

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Have you ever received personal training before?

Breif history of physical activity/sports

What are your desired goals?

Frequency per Week

2 3 4 5

Any Injuries? Please list and include date(s)

Any Surgeries? Please list and include date(s)

Pre-existing Health Issues

Cardiovascular

Respiratory

Systemic/Other

ACCURACY OF INFORMATION

I certify that the above medical information is correct to my knowledge.

PRIVACY AND SHARING OF INFORMATION

I authorize the clinic and its associated health professionals to collect my personal and medical information as documented above.

CANCELLATION POLICY

Your appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in the therapists' day that could have been filled by another patient. As such, we require 24 hours notice for any cancellations or changes to your appointment. Patients who provide less than 24 hours notice, or miss their appointment, will be charged a cancellation fee to the card on file. When enrolled on any online coaching option/program, cancellation must be done until the last day of the month prior to the abandonment of the service. If cancellation is not communicated on time, payment for the full month will still be expected.

Waiver and Release Form

Because physical exercise can be strenuous and subject to risk of serious injury, your personal trainer urges you to obtain a physical examination from a doctor before beginning any exercise or training program. You agree that by participating in these physical exercise sessions or personal training activities, you do so entirely at your own risk. This includes, without limitation, (a) your use of all amenities and equipment in the facility and any off site location and your participation in any activity, class, program, personal training or instruction, (b) the sudden and unforeseen malfunctioning of any equipment (c) our instruction, training, supervision, or dietary recommendations. You agree that you are voluntarily participating in these activities and use of these facilities and premises and assume all risks of injury. You expressly agree to release and discharge your personal trainer or instructor, and from any and all claims or causes of action. This waiver and release of liability includes, without limitation, all injuries to you which may occur, regardless of negligence. If any portion of this release from liability shall be deemed by a Court of competent jurisdiction to be invalid, then the remainder of this release from liability shall remain in full force and effect and the offending provision or provisions severed here from.

I acknowledge that I have carefully read this waiver and release and fully understand that it is a release of liability. I agree to voluntarily give up any right that I may otherwise have to bring a legal action against the personal trainer for negligence, or any other personal injury or property damage or loss action.

By typing your name as signature below, you agree to the terms and provisions of this agreement.

Client Intake Form

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