Patient Intake Form

For items 3 and 4, please select the one number that best describes your current ability to participate in each of these activities.

Informed Consent

I acknowledge that I may be engaging in physical exercise while attending any service provided by

Leaping Giraffes Pty Ltd t/a Anchorage Drive Physiotherapy or Drovers Elite Physiotherapy (hereinafter referred to as “the clinic”) facilities or facilities which the clinic utilises for the purpose of teaching exercises, which could cause me inujry. I hereby state that I am and will be voluntarily participating in these activities, whether supervised or unsupervised and I hereby assume all risk of injury, which might result from these activities.

There exists a possibility of certain dangers when exercising. They may include abnormal blood pressure, fainting, irregular, fast or slow heart rhythm, and in rare instances the possibility of heart attack, stroke or death. It is important for you to realise that you may stop whenever you wish because of feelings of fatigue or any other discomfort.

Whilst every care will be taken it is impossible to predict the body’s exact response to exercise. Every effort will be made to minimise these risks by evaluation of preliminary information relating to your health and fitness and by observations during exercising in supervised exercise classes or exercise sessions.

I understand that there may be an elemenet of hands-on teaching / correction of the exercises during the Pilates, exercises classes or individual exercises prescription and I give consent to receive hands-on teaching of exercises unless I inform the Clinician directly about being unfomfortable about this.

I realise that If I swap to another class time the tacher may not have immediate access to my health delcaration form and that it is my responsibility to make them aware of any current or injury problems, my responsibility not to work beyond my usual level of difficulty and to make my own adaptations as needed.

I will inform the Clinician of the Clinic’s group classes and my treating physiotherapist of any changes to my health which may affect my ability to exercise. I hereby waive and release any and all claims that I now have or may have against the clinic, its employees or agents for injury sustained by the clinic as a result of participation in physical execrcises and activities.

I hereby acknowledge that I have carefully read this waiver and thus fully understand that it is a release of liability of the clinic and I agree that such a waiver release is reasonable and proper based on the nature of services provided by the clinic.