Intake Form Intake Form "*" indicates required fields Name* First Last Today's Date* MM slash DD slash YYYY Phone*Email* Have you had any surgeries? If so when?Have you seen a physical therapist in the past five years? Please describe.Are you currently pregnant or have you been pregnant in the last five years?* Yes No Is there anything else we should know about your body?What are you hoping to achieve by taking Pilates?What is your most important fitness goal?Has your doctor recommended pilates?* Yes No Do you know about the Flex Spending Account? Yes No If not please ask Carey or admin to give you more information on this. CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.Do you agree to storage of your data?* Yes By submitting this form, you hereby agree that we may collect, store and process your data that you provided. Δ
