Thank you for your interest in working with Totally Designed Body, Inc. We look forward to meeting with you personally, but before we do so, there are some things we would like you to review. In this package you will find a brochure on our company, a rate sheet and our cancellation policy – so that you know a bit about us.
If you choose to work with us, we will also need to know a bit about you – therefore, we have included a Lifestyle and Health History questionnaire. A Medical Clearance form must be filled out by your doctor. Please download the Medical Clearance form separately and have your doctor fill it out and fax it to 212.868.1015 or mail it to Totally Designed Body, Inc., PO Box 2369, New York, NY 10108.
Also included are the following:
We look forward to hearing from you and helping you achieve optimal health! Our phone number is 212.868.1015. Please feel free to call if you have any questions.
Best of health to you,
Tara Dawn Bach-Martinez, President Totally Designed Body, Inc.
Victor Martinez, Vice President Totally Designed Body, Inc.
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Name:*
D.O.B: *
Address: *
E-mail: *
Phone: Day Eve Height: Weight:
Emergency Contact:
Relationship: Phone:
Name of Doctor: Dr.'s Phone #:
Are you currently taking any medications? Yes No
If yes, please list medication and reason for taking
Do you now, or have you had in the past:
Chest Pains? Yes No
Any chronic illness or condition? Yes No
High Blood Pressure? Yes No
Surgery? Yes No
Pregnancy? Yes No
Breathing or lung problems? Yes No
Muscle, joint or back problems? Yes No
Diabetes or thyroid condition? Yes No
Cigarette habit? Yes No
History of anorexia or bulimia? Yes No
High Cholesterol? Yes No
Hernia or any condition that may be aggravated by lifting weights? Yes No
Osteoporosis/Osteopenia? Yes No
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If you answered YES to any of the questions listed previously, please explain below:
When was the last time you exercised?
Do you exercise regularly? Yes No
If so, how often?
As a child or as an adult, what sports have you done?
How many meals do you eat daily? Snacks Glasses of water Coffee Alcohol
What kinds of food do you snack on?
Do you eat “fast foods”? Yes No
If yes, what kinds? How often?
Are your parents alive? Mother: Yes No Father: Yes No
If not, what was the age of death? Mother: Father:
If not, what was the cause of death? Mother: Father:
In detail, describe specifically what you would like to accomplish through your fitness program: What has prevented you from your goal(s) in the past?
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* In-gym sessions require a gym fee of $17.
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I, , (hereinafter “trainee”) hereby acknowledge that I have voluntarily applied to participate in one or more Personal Fitness programs offered by Totally Designed Body, Inc.
I AM AWARE THAT ALL FORMS OF EXERCISE INCLUDING BUT NOT LIMITED TO AEROBIC ACTIVITY AND WEIGHT LIFTING, YOGA, PILATES, AIS STRETCH, MAY BE HAZARDOUS ACTIVITIES. I AM VOLUNTARILY PARTICIPATING IN THESE ACTIVITIES WITH FULL KNOWLEDGE OF THE DANGER AND RISK TO BE INVOLVED AND HEREBY AGREE TO ACCEPT ANY AND ALL RISKS OF INJURY.
I hereby certify that (1) I have accurately and honestly completed the Health and Personal Injury Questionnaire, (2) I am not suffering from any physical disability, and (3) I am physically and mentally able to participate in the programs offered by Totally Designed Body, Inc. or any trainers/teachers/therapists affiliated with Totally Designed Body, Inc
.As lawful consideration for being permitted by Totally Designed Body, Inc. or any affiliated organization to participate in any of its programs, I hereby agree that I, my heirs, distributees, guardians, legal representatives and assigns will not make a claim against, sue, attach the property of or prosecute Totally Designed Body, Inc. or any employee, agent, representative or person affiliated with Totally Designed Body, Inc. for injury or damage resulting from the negligence or other acts, however caused, by an employee, agent or representative of Totally Designed Body, Inc. or one of its affiliated organizations, as a result of my participation in the Exercise and or Lifestyle and Weight Management Program.
In addition, I hereby relieve and discharge Totally Designed Body, Inc. and all employees, officers, directors, shareholders, agents or representatives of the aforementioned organization, from all actions, claims, or demands I, my heirs, guardians, legal representatives or assigns now have, or may hereafter have, for injury or damage resulting from my participation in any of the Totally Designed Body, Inc. programs including, but not limited to, aerobic exercise and weight lifting.
Before signing this form, please ask any questions regarding any aspect of the program or this form that may be unclear to you.
I have read and understand the Release of Liability One-On-One Training.
Please Accept the Release of Liability One-On-One Training
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Description of the Fitness Program:
Each session may incorporate a variety of training methods, including aerobic conditioning to improve the functioning of the cardiorespiratory system, pilates, yoga, resistance training to strengthen the musculoskeletal system, stretching and mobility exercises to increase flexibility and range of motion, and stability exercises to improve daily functioning of stability and balance. Although the program is designed to increase overall fitness and health, no guarantee of improvement can be promised. However, results generally will occur best and most rapidly when the client participates in the exercise program on a 3-times-per-week basis.
Risk of the Fitness Program:
Soreness, fatigue and muscular discomfort may occur after you begin any exercise program. Discomforts generally decrease with continuation of the program and physical improvement. However, if these or any other symptoms persist, the client should consult his/her physician and will not hold Totally Designed Body, Inc. or any trainer affiliated with Totally Designed Body, Inc. responsible. The reaction of the cardiovascular system to exercise cannot always be predicted with complete accuracy. Therefore, there is a risk of certain changes occurring during or following exercise. These changes can include, but are not limited to, abnormalities of blood pressure or heart rate and, rarely, cardiac complications. Should you experience any adverse signs or symptoms you should take the following two steps immediately:
Every effort is made to avoid any adverse reactions, through the use of the Health and Personal Inventory questionnaire (which you have filled out), the initial interview that is conducted, as well as observations made by the trainer during each exercise session.Before signing this form, please ask any questions regarding any aspect of this program that may be unclear to you.
I have read and understand the Informed Consent for Exercise Program One-On-One Personal Training.
Please Accept the Informed Consent for Exercise Program One-On-One Personal Training
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24 Hour Cancellation Policy! All gym sessions cancelled without 24 hours notice will be charged full price.
48 Hour Cancellation Policy! All home sessions cancelled without 48 hours notice will be charged full price.
Locked-in appointment times will be available only for clients purchasing packages. We will do our best to accommodate single-session clients, but the time slots cannot be guaranteed. A 10-session series must be paid for prior to the first training session; otherwise, the single-session rate will be charged and must be paid for at the time of service.
If you are planning to be away and will not be keeping your appointment, please call your trainer with any schedule changes as soon as possible. Clients who miss appointments with regularity will be asked to submit a retainer fee to keep scheduled time slots available. We thank you for respecting our terms.
I have read and understand the 24 Hour Cancellation Policy and 48 Hour Cancellation Policy.
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