Client Intake Form

Email:*

First Name:*

Last Name:*

Address:*

City:*

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Zip Code:*

Birthday (mm/dd/yyyy):*

Phone Number:*

Occupation/Work Duties:

Employer:

Physician:

Physician Phone Number:

Emergency Contact

First Name:*

Last Name:*

Phone Number:*

Other/Additional Information and Explanations:

List all current medications (include prescriptions, vitamins, supplements):*

Regular physical exercise/activities:*

Coupon code (if applicable):

Please state the reasons you are seeking our services (What can we do for you):*

Liability Release and Waiver of Claims:

By clicking below, I acknowledge that I am voluntarily participating in physical training and activities provided by Your Body Mechanic LLC. I understand that physical exercise carries inherent risks, including but not limited to, injuries, muscle soreness, and potential medical issues. I release Your Body Mechanic LLC, its trainers, employees, and affiliates from any and all liability for injuries or damages that may occur during my participation in training sessions. I affirm that I am in good physical health and have consulted a physician if necessary. I understand that I assume full responsibility for any risks or injuries.

I agree to the terms of the Liability Release and Waiver of Claims.

*By clicking the submit button I agree to the Prehab Terms and Conditions , and certify the above information to be accurate.