My Business - Intake Form

ph: +96560443060
alt: +919689983542
jacksanfernandes@gmail.com

Intake Form

Intake form

*First Name:

*Last Name:

*Email:

*Mobile Phone:

*Contact Preference:

*Address Line 1:

Country:

Join Mailing List?

Please add me to your mailing list.

Web Site:

*Service Requested:

Emergency Contact Name

Emergency Contact Phone:

*Please state if you have current/previous health diseases/issues :

*Please State if you are taking any medication:

*Do you smoke? :

Yes No

*Have you had any surgery since one year? :

Yes No

*Do you feel pain while doing sports/exercise? :

Yes No

Release and Acknowledgement :

I, , hereby acknowledge that the information I've given above is complete and accurate. I understand all the risks and I accept all the responsibility for any undesired situations during training. I am informed that my information in this form will be kept confidential.

The center has informed me that I am the only responsible party both for all the injuries during the fitness program and incorrect information. I release and discharge the center trainers, administration and workers from any disclosure of my personal information in this Client Intake Form.

If any of my health, lifestyle or personal information/situation that may prevent my training is changed, I guarantee that I will inform the center authorities immediately.

I Authorize

Comments:

Submit Your Message:

ph: +96560443060
alt: +919689983542
jacksanfernandes@gmail.com

Intake Form

Intake form

Release and Acknowledgement :