embrace physio + pilates Movement and Education Pregnancy Event. Medical Clearance & Participant Information Form Participant Information Name * First Name Last Name Date of Birth * MM DD YYYY Contact Number * (###) ### #### Email * Pregnancy Information: Current Gestation (weeks) * Due Date * Are you experiencing any pregnancy complications? (e.g., high blood pressure, gestational diabetes, placenta previa, preterm labor risk, etc.) * Yes No If yes, please specify Do you have any medical conditions that may affect your ability to participate in movement-based activities? * Yes No If yes, please specify Have you seen a Pelvic Health Physiotherapist during this pregnancy? * Yes No If yes, please specify please specify any concerns addressed Birth Preferences: Do you have any specific birth preferences that you would like to share? (e.g., vaginal birth, planned cesarean, pain management preferences, perineal preparation, etc.) Informed Consent: By signing and submitting this form, I acknowledge that the movement and educational session is designed to be safe and beneficial for pregnant individuals; however, I understand that participation is voluntary. I confirm that I have disclosed all relevant medical information and understand that it is my responsibility to notify the facilitator of any changes in my pregnancy or health status. I agree to participate at my own risk and release the event facilitator and venue from any liability associated with my participation. Name * Date * MM DD YYYY I agree to be contacted by Embrace Physio + Pilates after the event for a prenatal assessment and follow-up support. I agree Thank you!
