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728 Nostrand Avenue
Brooklyn, NY, 11216
718-484-2295
where movement and wellness meet
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Welcome
Team
Pilates
Group Classes
Private Pilates Sessions
Book Pilates Sessions & Packages
Massage
NEW CLIENT OFFERS
Forms
Pilates Consent Form
Massage Consent Form
Gift OFFERS
Resources
Name
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
Date of Birth
MM
DD
YYYY
Emergency Contact
*
First Name
Last Name
Phone
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
What brings you in for a massage?
*
Are you pregnant? If yes, what is the due date?
*
Please list any medications that you are currently taking.
*
List any surgeries and corresponding dates:
*
I have conditions in the following categories:
*
Please select all applicable categories and provide details in the textbox below
I have none of these
Musculoskeletal (osteoporosis, arthritis, bone disease etc.)
Circulatory (heart condiditon, blood clots, blood pressure issues, etc.)
Respiratory (breathing problems, allergies, sinus problems, etc.)
Nervous system (shingles, pinched nerve, MS, chronic pain, etc.)
Reproductive (ovarian or prostate problems)
Skin (allergies, rashes, cosmetic surgery, athlete's foot, etc.)
Digestive (IBS, bladder or kidney, ulcers, Chron's disease, etc.)
Psychological (anxiety, depression, etc.)
Cancer
Assistive devices (dentures, hearing aids, contacts, etc.)
Low energy levels - sleepy/lack motivation
High energy levels - trouble relaxing/falling asleep/nervous energy
Run hot temperature wise
Run cold temperature wise
Do you have pain anywhere?
If you checked any of the above please provide details
Waiver
*
I acknowledge and agree to the following: I have volunteered to participate in and receive manual therapy at Lula Body Pilates Studio. I understand that this is not a substitute for medical or psychological care. Any information shared within the session is not prescriptive but for educational/informational purposes only. All information shared within the session is purely confidential. It is my responsibility to ascertain that there is no medical reason to prevent my participation. I acknowledge that if there is any medical reason that may affect my ability to participate in a massage therapy session, I will consult my physician to approve participation. I assume all of the foregoing risks and accept personal responsibility for any other damages or other injury I might suffer. I understand that my email address and mobile number will be used for appointment confirmations, updates and other communications from Lula Body. I have read and understand this informed consent and waiver and release of liability and accurately set forth my intentions and I agree to be bound by its provisions.
I agree
Vaccination Status
*
I have been vaccinated against Covid-19
Yes
No
Covid-19 health Status
*
I have not had a fever in the last 24 hours. I have not been in close contact with anyone who is Covid positive in the last 10 days. I have no loss of smell or taste in the last 10 days. I have not experienced any muscle soreness or aches or pains that may be associated with Covid-19 in the last 10 days
I Agree
Thank you!