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Name *

First Name

Last Name

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a healthcare professional? *

Yes

No

Do you experience chest pain or discomfort during physical activity? *

Yes

No

In the past month, have you experienced chest pain or discomfort while not engaged in physical activity? *

Yes

No

Do you lose consciousness or ever lose your balance due to dizziness? *

Yes

No

Do you have a bone or joint problem that could be aggravated by exercise? *

Yes

No

Is your doctor currently prescribing medications for your blood pressure or a heart condition? *

Yes

No

Are you aware of any other reason why you should not engage in physical activity? *

Yes

No

Cancellation Policy/Consent

Thank you for choosing Immersion PNW to assist you in reaching your goals. Your success in achieving better overall health requires dedication and consistency, and I am fully committed to supporting you throughout this journey. To ensure effective continuity of care, I kindly request that you provide at least a 24-hour notice in the event of a cancellation. If, for any reason, you are unable to give a 24-hour notice and need to cancel your appointment, the full price of the scheduled session will be applicable. Likewise, I will adhere to the same policy should I need to reschedule our session. I understand that unforeseen circumstances may arise, and I am willing to consider exceptions to the cancellation policy on a case-by-case basis. If you encounter any extenuating circumstances, please discuss them with me. By filling out this form, I give consent to Immersion PNW services and adhere to the operations of the business. I assume all liability and am aware of risks and benefits associated. I am looking forward to working with you and assisting you in achieving your lifestyle goals.

I Consent

I Do Not Consent