Client Intake

 

The Belly Studio

Arlene Corcoran, M.FA., N.C.P.T.
email: thebellystudio@gmail.com
email: arlene@thebellystudio.com

Text or Message: 520-661-0321
6120 East 5th Street, Unit A114, Tucson, AZ​

Emergency Contact

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Employment

Health Screening

Please fill out this form to the best of your ability and sign the statement at the bottom of the Heath Screening Section as in all sections. If you have any questions, please feel free to ask us.
GENERAL HEALTH:

Health details

CURRENT OR PREVIOUS DIAGNOSED CONDITIONS?

General History

Release & Waiver

I, ______ voluntarily desire Lo participate in physical and/or rehabilitative exercise training conducted by The Belly Studio, LLC. and Arlene Corcoran, N.C.P.T., located at 5714 E. 2nd Street Tucson AZ 85711, and understand and agree with the following: 

1. I assume full responsibility while voluntarily participating in any training class at my sole risk and shall abide by and all rules and regulations for use of the facility which may be promulgated from time to time by its owner or The Belly Studio Pilates Studio. 

2.  I am aware that there exists the possibility of certain conditions occurring during or following training and/or exercise. These conditions include, but are not limited to: mild or light- headedness, fainting, abnormalities of blood pressure or heart rate, ineffective heart function and in rare instances, heart attack and stroke. The reaction of the cardiovascular system to such activity cannot be predicted with complete accuracy. 

3. It is strongly recommended that I receive medical clearance from my private physician prior to starting this or any exercise training program. This program can be designed for persons with known heart disease or those with disorders which require medical supervision however, those persons should have a direct physician referral. The Belly Studio, LL.C. reserves the right to deny services LO those without their physicians' written consent and/or referral. 

4. I expressly agree that I have been informed that the program involves possible risks and all exercises shall be undertaken at my sole risk and that neither The Belly Studio, L.L.C., nor its officers, directors, agents or employees shall be liable to me or any other person, for any claims, demands, injuries, damages, actions or causes of action, whatsoever, to my person or property arising out of or connect Lo services and/or exercises having direct relation to this facility. I do hereby release and discharge The Belly Studio, L.L.C. thereof from all claims, demands, injuries, damages, actions, or causes of action and from all acts of active or passive negligence on the part of The Belly Studio, LLC. or their officers, directors, agents or employees. 

4.15. I acknowledge that I am expected LO wear appropriate exercise auire. This includes yoga pants, sweat pants, along with other soft fabrics and excludes denim jeans and other firm, stiff fabrics. I also agree LO avoid wearing scented 

Thursday, March 21, 2024 The Belly Studio Intake of CLIENT I TAKE FORM products such as fragrances or scented lotions, as these may cause adverse health effects in closed-circulation rooms where people are exercising. 

5. I am aware that if I no-show or cancel my training appointment within 12 hours of my appoimmenl Lime I will be charged $75 Late Cancel Fee. 

6. Services purchased will have a corresponding expiration date. Credits beyond the expiration date will not be honored, nor will a refund be issued. 

I HAVE READ THE ABOVE STATEMENT AND UNDERSTAND THE ABOVE CONDITIONS.

Video & Photo Release Agreement:

I hereby grant The Belly Studio, L.L.C. permission to use my likeness in a photograph or video in any and all of its publications, including website entries, without payment or other remuneration or consideration. I understand and agree that these materials will become the property of The Belly Studio, L.L.C. and will not be returned. I hereby irrevocably authorize The Belly Studio, L.L.C. and will not be returned. I hereby irrevocably authorize The Belly Studio, L.L.C. to edit, alter, copy, exhibit, publish or distribute this photo for the purposes of publicizing The Belly Studio, L.L.C.'s programs or for any other lawful purpose. In addition, I waive the right to inspect or approve the Finished product, including written or electronic copy, wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photograph. I hereby hold harmless and release and forever discharge The Belly Studio L.L.C. from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization. I am at least 21 years of age or older and am competent to contract in my own name. I have read this release before signing below and I fully understand the contents, meaning, and impact of this release.
If the person signing is under age 21, there must be consent by a parent or guardian, as follows: I hereby certify that I am the parent or guardian of __________________ _______________ , named above, and do hereby give my consent without reservation to the foregoing on behalf of this person.

Mark the areas of your body that give you pain or concern:

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