Booking Form

Hybrid Class Re-Booking Form

Please complete all required fields!

Customer Information

Full Name*

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DOB*

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What are your preferred pronouns

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Preferred Pronoun

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Email*

Please specify your email address.

Mobile*

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Your Address

Address 1

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Address 2

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Town

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County

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Post Code

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Emergency Contact Details

Your GP

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Emergency Contact Name

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Emergency Contact Number

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About Your Course(s)

Dates of Courses Booked*

January - March

April - June

July - September

October - December

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Year

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Class Booking 1
only book the class you already attend or if you have received confirmation space is available for you in that chosen class*

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Class Booking 1 - Face To Face or Online?*

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Class Booking 2

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Class Booking 2 - Face To Face or Online?

Face To FaceOnline Invalid Input

Class Booking 3

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Class Booking 3 - Face To Face or Online?

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Fees

Cost
(self-funding discounted fees)

Clinic face-to-face course of PILATES classes - £110

Clinic face-to-face course of PILATES classes PLUS pre-recorded class - £137.50

Clinic face-to-face course of PILATES classes x2 - £220

Clinic face-to-face course of PILATES classes x2 PLUS pre-recorded class - £257.50

Live online course of PILATES classes - £99

Live online course of PILATES classes PLUS pre-recorded class - £123.75

Live online course of PILATES classes x2 - £198

Live online course of PILATES classes x2 PLUS pre-recorded class - £231.75

Neuro Pilates - clinic face-to-face course of PILATES classes - £66

Neuro Pilates - live online course of PILATES classes - £59.40

Pre-recorded course of PILATES classes - £50

PD Exercise classes (clinic & online) - £120-£180 (tbc)

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Preferred Payment Method*

Third party funding (including PHB funding - we will contact you regarding fees / who to invoice)

BACS transfer - Bank details will be included on your invoice

Monthly Standing Order - Bank details will be included on your invoice

Cheque (made payable to “Pilates Clinic Retford” & posted to: Pilates Clinic Retford, Dental 22 Buildings, Chapelgate, Retford. DN22 6PL).

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Additional Information

Dates you cannot attend class

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Preferred weeks for pre-recorded catch-up class

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Current Medical History

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Pregnancy (if applicable)

Are you pregnant?

YesNoNot Applicable Invalid Input

If 'yes', when is the due date?

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If 'yes', have you had any complications with your pregnancy?

YesNo Invalid Input

Any Other Comments

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THIS INFORMATION IS PROTECTED BY THE DATA PROTECTION ACT 2018

Please check all boxes below to confirm you understand our terms and conditions.

The checking of the below boxes and the submission of the form will be regarded as a digital signature and date stamp in agreement to all terms included.

Please read and check all boxes to confirm*

I understand that the Pilates / PD Exercise Class will begin at a low level and will be advanced in stages depending on my ability and fitness level and ongoing assessment. I will exercise at my own rate and within my own level of comfort and ability, and I realise that I may stop exercising at any time because of feelings of discomfort, pain or fatigue. Invalid Input. Please check all boxes.

I understand that there exists the possibility of certain dangers when exercising. These include abnormal blood pressure, fainting, abnormal heart rhythm and in rare cases, heart attack, stroke or death. While every care will be taken, it is impossible to predict the body’s exact response to exercise. Invalid Input

I understand that these sessions are not a substitute for medical advice or treatment. If I have any doubts about the suitability of the exercises I will refer back to my medical practitioner. I confirm that my doctor has not advised me against such exercise. I understand that it is advisable to inform my GP prior to starting any new form of physical exercise. Invalid Input

If for any reason my health or ability to exercise changes, I will inform my Physiotherapist before the class commences. Invalid Input

My Physiotherapist reserves the right to stop a course of treatment at any time if they believe, in their professional opinion, that it is in the interests of me, the Client, or them, the Physiotherapist, for the treatment to stop. Invalid Input

I understand that I must observe and follow instructions on safety and technique to protect both myself and other class members. I also understand that I may be asked to stop attending classes if I fail to follow these instructions. Invalid Input

I understand that all pre-recorded classes are general mixed ability Pilates classes and not tailored to any individual member’s needs. If I am practicing a pre-recorded class I understand that my Therapist will not be able to provide personalised advice, corrections, modifications or feedback during that class. I know that if there is anything I am uncertain about I am to contact my Physiotherapist or GP before starting the class. Invalid Input

I understand: 1. Once a course of classes has commenced, no refund can be given for missed sessions. 2. If a session is cancelled by the Physiotherapist, a credit note or refund will be given for that session. 3. Pre-recorded Pilates classes are the only option for catch-up if I can’t attend my regular LIVE class. If I already receive these classes each week in addition to my live class (at the discounted rate), then there will be no additional catch-up classes available. 4. A minimum of 6 clients must be booked onto an online course for that course to run. If this number is not met, an alternative class will be offered, or a full refund will be given. Invalid Input

I understand: 1. If I decide not to attend a face-to-face class for any reason, I can still attend that SAME live class online via Zoom. 2. If there is a further lock-down, circuit-breaker, or any other situation out-with the control of the clinic that means live face-to-face classes cannot be run (heavy snow or extreme heat for example), classes will be run live online via Zoom only. 3. If I cannot attend such classes online, then refunds will only be given if more than 2 classes are not taught face-to-face (current courses are 12 weeks for the price of 10; the same price as 10 classes). Invalid Input

I understand that: Pilates classes may be observed by Physiotherapy, APPI and work experience students (additional consent will be sought for observation of private 1:1 sessions). Invalid Input

I confirm that I have read in full the instructions provided regarding live online classes and pre-recorded classes, including what I need to know and what I need to do for my own safety, for confidentiality and for compliance with GDPR. Invalid Input

I understand that live online classes or treatment can NOT be attended if I am physically in USA, Canada or Australia, but I can request recorded classes to make-up for missed classes when I am physically in UK. Invalid Input

I confirm that I have read in full the instructions provided regarding live face-to-face clinic-based classes, including what I need to know and what I need to do for infection control, for my own safety and for the safety of others, for confidentiality, and for compliance with GDPR. Invalid Input

I acknowledge that I have read this form in its entirety or it has been read to me. I have completed all sections in full and the information I have given is correct. I understand my responsibility in the Exercise Classes in which I will be engaged. I accept the risks, rules, and regulations set forth. Knowing these, and having had an opportunity to ask questions which have been answered to my satisfaction, I consent to participate in Exercise Classes / 1:1 sessions. Invalid Input

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