Personal Training and Nutrition Client Intake Form

Fitness Training and Nutrition Counseling New Client Information

Please fill out the below form to the best of your ability. Try to provide as much detail as possible so our therapists and trainers can formulate the best solutions for you. Thank you for choosing TAB Massage and Fitness, Inc. for your alternative health needs. We strive to "Create A Happier, Healthier, You!"
Personal Information
First Name*
Middle Initial
Last Name*
Street Address 1*
Street Address 2
City*
State*
Zip*
Country
Gender*
Birthday*

MonthDayYear
Main Phone*

Area CodePhone Number
Other Phone

Area CodePhone Number
Email Address*
Referral*
Referred By:
Other Referral
Emergency Contact*
Emergency contact number*

Area CodePhone Number
Occupation*
Health Insurance Provider*
Primary care physician*
Date of Last Physical*
Desired Services*

Fitness TrainingNutrition CoachingStretching

Liability Waiver, Release and Indemnification Agreement
I, the undersigned, being aware of my own health and physical condition, and having knowledge that my participation in any exercise program may be injurious to my health, am voluntarily participating in physical activity with the certified personal trainers at TAB Massage and Fitness.

Having such knowledge, I hereby release TAB Massage and Fitness and their representatives, agents, and successors from liability for accidental injury or illness which I may incur as a result of participating in the said physical activity. I hereby assume all risks connected therewith and consent to participate in said program.

I agree to disclose any physical limitations, disabilities, ailments, or impairments which may affect my ability to participate in said fitness program.
Electronic Signature Authorization
Signature*
Today's Date*

MonthDayYear
Please make sure you are human*
Consent to Treatment of Minor: By my digital signature below, I hereby authorize TAB Massage and Fitness,Inc. to administer massage, bodywork, somatic therapy techniques, fitness training, nutrition counseling or stretching to my child or dependent as they deem necessary.
Parent/Legal Guardian
Signature
Child/Dependent
Signature
Today's Date

MonthDayYear
Phone Number

Area CodePhone Number
Should be Empty:

Fitness Training and Nutrition Counseling New Client Information