Contact meI offer a free initial consultation to answer new clients' questions over the phone or zoom.Whether you have a general question, or would like to inquire about a consultation, I’d love to hear from you!I will respond to your email within 24-48 hours. Name * First Name Last Name Email * Message * Thank you! New Client Intake Form Name * First Name Last Name Date of Birth * MM DD YYYY Gender * Female Male Non-Binary / Gender Fluid Pronouns * She / Her He / Him They / Them Other Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact Name * First Name Last Name Emergency Contact Relationship * Emergency Contact Phone * (###) ### #### Do you have a PRIMARY injury or area of concern that I should know about? * Lower Back Headaches Ankle Elbow Upper Back Hip Foot Wrist Neck Knee Shoulder None Other Let me know more about your primary injury or area of concern here * Do you have a SECONDARY injury or area of concern I should know about? * Lower Back Headaches Ankle Elbow Upper Back Hip Foot Wrist Neck Knee Shoulder None Other Let me know more about your secondary injury or area of concern here * Do you have any existing medical conditions you want me to know about? * Osteoporosis Osteoarthritis Multiple sclerosis Parkinson’s Disease Rheumatoid Arthritis Chronic Pain Chronic Fatigue Syndrome History of Cancer Sprain Degenerative Disc Disease Tendinitis Bursitis Pregnancy Scoliosis Hypermobility syndromes Fibromyalgia Other None Let me know more about your existing medical conditions here * If you are here for a private Pilates consultation, have you had any past training with Pilates? * What days and times are you available? * Are you interested in working in person, online, or both? * What are your goals with Pilates, or Yoga? * Are you working with a physical therapist, chiropractor, or healthcare provider? * Yes No If so, please provide a name in the space below: Policy and Medical Liability Waiver * Please agree to all of the policies by signing below. All sessions are by appointment only and paid for at the instructor’s rate. 24 Hour Notice To offer the best experience for each client, please give 24-hours notice if you are unable to keep your scheduled session. Cancelled or changed sessions within 24 hours will be charged in full. Submitting this form indicates that you have read and agree to Registration Policies and Liability Agreement. Cancellations, Payments, and Schedule Changes All classes and private sessions are by appointment only. After your first appointment, you may purchase private packages. 24-hour advance notice is required to change or cancel an appointment without charge. All private and group appointments may be cancelled by phone, email, or in person. In the event the instructor has to cancel a class, your instructor will make every attempt to notify you within 24 hours. General Information and Etiquette To achieve the results you are seeking, we recommend attending private sessions or group classes two to three times per week, and augment with independent, at home work using simple props and tips from your private sessions. Wear comfortable, well-fitting exercise clothes. Baggy tops and pants may obscure your body and make it difficult for your instructor to correct your form and alignment. Many people are comfortable wearing socks. Clean shoes may be advised for clients who use orthotics. Kindly refrain from using cell phones. Please avoid wearing perfumes or scents. If you are practicing Pilates before pregnancy, you can safely continue through your pregnancy with permission from your doctor. Policies and Procedures Injury Request that students postpone training due to an injury. Alexia Miller Medical Waiver As your instructor, I am trained in a variety of exercise systems and specialties and can develop a STOTT PILATES, Yoga, Somatics, ZENGA, Fascial Movement Exercise, or other program (“hereinafter Pilates, Yoga or other Program”) for you. The Pilates, Yoga or other Programs of exercise may or may not be beneficial to you. It is advised that you first consult with your physician about any injuries or existing medical conditions, past or present, before enrolling in any private or group class. I would be happy to speak with your physician or call for a release form on your behalf. PLEASE READ CAREFULLY! THIS IS A RELEASE AND WAIVER OF CERTAIN LEGAL RIGHTS. Participant understands that Pilates and Yoga involve physical exertion; are strenuous, and that injuries may occur when participating in such activities. Participant accepts and assumes the risks associated with Pilates, Yoga or other Program, including, but not limited to, equipment malfunction or failure, overexertion, inability to perform suggested exercises or maneuvers, physical or mental conditions that impede the ability to properly perform suggested exercises or maneuvers, failure to properly operate equipment, and failure to follow instructions. Participant hereby freely and expressly assumes all risk of property damage, injury, and death associated with Pilates and Yoga. Participant understands that it is his/her responsibility to consult with a physician prior to and regarding participation in Pilates or Yoga. Participant represents and warrants that he/she has no physical or mental condition that would prevent full participation in Pilates or Yoga. Participant agrees to inform his/her instructor immediately of any physical or mental condition that would prevent his/her full participation in Pilates or Yoga. In consideration for participation, receiving instruction in a group, private or semi-private lessons,Participant hereby agrees to release, hold harmless, and indemnify Alexia Miller from any and all claims by or on behalf of Participant against Alexia Miller arising directly or indirectly out of Participant’s participation in Pilates or Yoga, use of any equipment or facilities. This release includes claims and liabilities arising from any cause whatsoever, including, but not limited to, negligence on the part of Alexia Miller. This release is binding upon Participant, and Participant’s heirs, assigns, and legal representatives. If signing on behalf of a minor Participant, Parent/Guardian accepts full responsibility for any medical expenses incurred due to the minor’s participation in Pilates or Yoga and agrees to release, hold harmless, and indemnify (including costs and attorney’s fees) Alexia Miller for any claims brought by or on behalf of the minor. I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above. Name (E-Signature) * First Name Last Name Parent/Legal Guardian Name (E-Signature) If the participant is under 18 First Name Last Name Today's Date * MM DD YYYY Thank you!
