Balanced BodyWorks Registration Form Order Number First Name * First Name Last Name * Last Name Address * Address City * City Zip * Zip Home Phone * Home Phone Work Phone Work Phone Cell Phone Cell Phone Email Address * Email Address Please indicate if you have any of the following conditions that may keep you from physical activity (Check all that apply): Arthritis Osteoporosis Foot/Ankle Knee/Thigh Lower Back Head/Neck Pain Scoliosis Stenosis Shoulder/Clavicle Hip/Pelvis Tennis/Golf Elbow Upper Back/Shoulder Blade Wrist/Hand Bone Fracture Have you had any surgeries, health conditions we should be aware of? If yes, explain: FEES: Pilates Private:Single Session: $8010 Session Package: $70020 Session Package: $1,380 Introduction package: $210(3 Private sessions - NEW CLIENTS ONLY) Duos (2 people):Single Session: $100 ($50 per person)10 Session Package: $900 ($450 per person) Group:Single Session: $2810 Session Package: $23020 Session Package: $440 FEES: Therapeutic Massage Therapeutic Massage, blade, Active Release Techniques (A.R.T.), Active Isolated Stretch (A.I.S.), Cupping90 mins: $140 - 60 mins: $83 - 25 mins: $4625-minutes: $50 60-minutes: $90 90-minutes: $140 Additional modalities added to massage session fee: Cupping: $10 Blading: $10 Rock Taping: $10 Ten-minute single treatments (NO massage) Per site: Cupping: $15 Blading: $15 Taping: $15 Sign up on a first-come basisPayment is due when services are renderedCancellation: 24-hour notice (no charge)Same day or no-show (full charge) Packages expire six (6) months from date of purchaseCash or Check only - Payable to Balanced BodyWorksMajor credit cards acceptedNO REFUNDS OR TRANSFERS How did you hear about our programs? Balanced BodyWorks is not responsible for any injuries a client may receive while on the premises. Each client assumes the risk involved in participating in any exercise-related sessions. Please consult with your physician before starting any exercise program. Reservations are not complete until payment has been made. Payments may be mailed or presented directly to Balanced BodyWorks . By submitting this form you are stipulating that you have read and understood the terms, fees and conditions stated above.