Online Intake Form | Evofitwell - Personal Training Wellness Center

Intake & liability Release

First name

Last name

Phone

Date of Birth

Address

Do you have injuries, Past or Current?

Yes

Please specify recent and past injuries. When? How? What is the injury?

Emergency Contact

Phone

Relationship

What is your occupation?

Referred by? Name of person, google, etc.

Are you taking and medications? If yes, please list:

Any allergies? (oils, lotions, nuts, fruits, skin, etc.)

Are you pregnant? If yes, how many months, and due date.

Are you currently under medical supervision or receiving other medical interventions? if yes, please explain.

What other conditions

Initials

I declare that the info I’ve provided is accurate & complete

I hereby acknowledge this release from liability for accidental injury or illness which I may incur as a result of participating in any physical activity. I hereby assume all risks connected therewith and consent to participate in this program. I agree to disclose my physical limitations, disabilities, ailments, or impairments which may affect my ability to participate in this program.

I accept terms & conditions

Thanks for submitting!