Please Fill Out Before Attending Your Initial Consultation

Functional Patterns Melbourne client WaIver and Pre-Session Information

Please fill out the medical waiver and questions in our form below. You can also read more about our cancellation policy. This streamlines the process for your session and lets us know if we have to refer you to a medical professional prior to undertaking any training.

If you have any questions about the below, please feel free to contact us to discuss. We look forward to seeing you and helping you to live intentionally, not habitually.

Please click ENTER once you have completed this form

Name *

First

Last

Email *

Sex *

D.O.B *

(DD/MM/YY)

Contact Number *

Post Code

Additional Notes

Please include any additional notes here for the listed items above

Please answer the following?

Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?
Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?
Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?
Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?
If you have diabetes (Type I or Type II), have you had trouble controlling your blood glucose in the last 3 months?
Do you have any undiagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise?
Do you have any other medical conditions that may make it dangerous for you to participate in physical activity/exercise?

Please give us a brief history of previous injuries and treatment: *

Please give us a brief summary of your current exercise, if any: *

What would you consider to be a successful result for you in 3-6 months time? *

How did you hear about us? *

CANCELLATION POLICY - We require a minimum of 24hr notice if you wish to cancel or reschedule. *

In the event you do not attend your scheduled appointment, with no reasonable explanation, you will incur a 100% payment fee for the session. This policy ensures other clients are able to access our services rather than being put on a waiting list or turned away. Please type "I agree" below.

I accept the terms of service below

Physical exercise can be strenuous and subject to risk of serious injury. We urge you to obtain a physical examination from a doctor before using any exercise equipment or participating in any exercise activity.

You agree that by participating in physical exercise or training activities, you do so entirely at your own risk. Any recommendation for changes in diet including the use of food supplements are entirely your responsibility and you should consult a physician prior to undergoing any dietary or food supplement changes.

You agree that you are voluntarily participating in these activities and use of these facilities and premises and assume all risks of injury, illness, or death.

We, the trainers at Functional Patterns Melbourne are also not responsible for any loss of your personal property.

You acknowledge that you have carefully read this "waiver and release" and fully understand that it is a release of liability.

You agree to release and discharge the trainer or instructor from any and all claims or causes of action and you agree to voluntarily give up or waive any right that you may otherwise have to bring a legal action against the trainer or instructor for personal injury or property damage. To the extent that statute or case law does not prohibit releases for negligence, this release is also for negligence.

If any portion of this release from liability shall be deemed by a Court of competent jurisdiction to be invalid, then the remainder of this release from liability shall remain in full force and effect and the offending provision or provisions severed here from.

By signing this release, I acknowledge that I understand its content and that this release cannot be modified orally.

Want to hear more?

get in touch

+61 458 904 881

melbourne@functionalpatterns.com

1/26 Breese Street
Brunswick, VIC
Australia

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