Consent Form & Cancellation Policy

First name

Phone

Last name

Birthday

Emergency Contact Number

Email

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Country

Do you have a physical disability or any health issues/conditions that I should be aware of? *

No

Yes

Are you experiencing any of the following?

Lower back pain

Upper back pain

Shoulder pain

Muscular pain

Numbness to any part of the body

Neck injury

Knee Surgery

Surgery

Seizures

Allergies

Are you pregnant? *

No

Yes

- Consent & Cancellation Policy -

Date

Initials

I confirm that the information given in this form is true

I accept terms & conditions

Thanks for submitting!

Move well, Move often.

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