POSEWELLNESS
Pose Wellness and Rehabilitation Services
THIRTY (30) DAY
MEMBERSHIP CONTRACT
Pursuant to the Fair Business Practices Act, O.C.G.A. § 10-1-393.2, all Georgia health spa/gym
contracts must contain the following language:
Pose Wellness and Rehabilitation Services offers a (30) thirty day membership for unlimited
group fitness classes specified for monthly membership. There is no contract beyond the (30)
thirty day membership purchase, no recurring charge, and no registration fee. Once your (30)
thirty day expires you will need to renew your (30) thirty day membership by paying on site, or
pay online for your next (30) thirty day membership for unlimited group fitness classes specified
for monthly membership.
The cost for the Monthly Membership is $24.99 for a (30) thirty day membership for unlimited
group fitness classes specified for monthly membership.
▪ You (the buyer) have seven business days to cancel this contract. To cancel, mail or hand
delivers a letter to the following address:
Pose Wellness and Rehabilitation Services
12160 Countyline Road
Suite104
Fayetteville, GA. 30215
Do not sign this contract if there are any blank spaces above. In the event optional services are
offered, be sure that any options you have not selected are lined through or that it is otherwise
indicated that you have not selected these options. It is recommended that you send your
cancellation notice by registered or certified mail, return receipt requested, in order to prove that
you did cancel. If you do hand deliver your cancellation, be sure to get a signed statement from
an official of the spa, acknowledging your cancellation.
To be effective, your cancellation must be postmarked by midnight, or hand delivered by
midnight on ______________________, and must include all contract forms, membership cards,
and any and all other documents and evidence of membership previously delivered to you.
▪ You (the buyer) may cancel this agreement within 30 days from the time you knew or should
have known of any substantial change in the services or programs available at the time you
joined. Substantial changes include, but are not limited to, changing from being coed to being
exclusively for one sex or vice versa. To cancel, send written notice of your cancellation to the
address provided in this contract for sending a notice of cancellation. The best way to cancel is
by keeping a photocopy and sending the cancellation by registered or certified mail, return
receipt requested.
▪ If you become totally and permanently disabled during your membership term, you may
cancel this contract. The health spa is entitled to a reasonable predetermined fee in such event,
in addition to an amount equal to the value of the services made available for use.
▪ If you have a history of heart disease, you should consult a physician before joining a spa.
▪ If you should die during the membership term or any renewal term, your estate may cancel
the contract. The health spa is entitled to a reasonable predetermined fee in such event, in
addition to an amount computed by dividing the total cost of your membership by the total
number of months of the membership and multiplying the result by the number of months
expired in the membership term. Reasonable proof of death may be required under this
paragraph.
▪ Under this contract, no further payments shall be due to anyone, including any purchaser of
any note associated with or contained in this contract, in the event the health spa at which the
contract is entered into ceases operation and fails to offer an alternate location, substantially
similar, within ten miles.
▪
NOTICE
State law requires that we inform you that should you (the buyer) choose to pay for any
part of this agreement in advance, be aware that you are paying for future services and
may be risking loss of your money in the event this health spa ceases to conduct business.
Health spas do not post a bond, and no other protections may be provided to you should
you choose to pay in advance.
Signature of member: __________________________________________________________
Date: ____________________________________________________________________
POSEWELLNESS
DISCLAIMER
GUESS_______________
MEMBER ID# ______________
Pose Wellness and Rehabilitation Services, is the community solution, where exercise along
with nutrition and mental health work together, creating a healthy preventative, permanent
solution for a balanced and physically fit body within a workout, live, play, and shop
environment.
I understand the various risks associated with an exercise program and it is my desire to
participate. I have not withheld any relevant information regarding my health, physical
condition or any other conditions, which may affect me during or following a session. If there
are any medical conditions that need clearance, it was cleared, and I have approval from my
physician or any other medical clearance needed to participate. I agree the instructor or any
other parties involve are not responsible for any injuries sustained by me during my exercise
sessions. If any injury should be obtained from participating, it will be covered by my
insurance and none of the other parties insurance.
I hereby release Pose Wellness and Rehabilitation Services L.L.C. also known as
posewellness.com, instructors, sponsors and other parties involve from any claim, action,
liability, loss, damage or suit arising from any hosted activities or events.
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DATE
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CLIENT SIGNATURE
DATE
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EMAIL
CELL #
POSEWELLNESS
CONFIDENTIAL INTAKE INFORMATION
THANK YOU FOR CHOOSING US
PERSONAL INFORMATION
DATE: _____/______/______
First Name_________________________ Last Name__________________________________
DOB: _____/______/______ Sex: M / F
Single/Married How many children? _________
Mailing Address:____________________________________________________________________________________
Home Phone: ________________________
Cell Phone: ___________________________
E-mail: _______________________________________________________________________
HEALTH INFORMATION
Height: ____________ Current Weight: ____________
Goal Weight: _______________
Waist Circumference: _________
BMI: _____________________________
What are your health goals? ________________________________________________________________________
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What are your main health concerns? _____________________________________________________________
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Women - Are you – Premenopausal ______ Menopausal ______ Post-hysterectomy ________
Men - Do you have prostate problems _______
Do you have: (Y/N)
High blood pressure _____ Diabetes _____ Arthritis _____ Heart disease _____ Sinusitis _____
Constipation _____ Gas _____ Bloating ____ Acid Reflux ____ Swelling ____ Depression ______
List any food Allergies/Sensitivities _______________________________________________________________
Any other illnesses/surgeries_______________________________________________________________________
_________________________________________________________________________________________________________
How many hours of sleep do you get each night? ________________________________________________
Do you exercise? _______ How often? _________
Do you take any supplements? ___________________
Do you take prescriptions medication? ____________________________________________________________
REASON FOR VISIT
Explain: _______________________________________________________________________________________________
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Do you have any pain? _________________________ Are you being treated for the pain? ____________
Did you get clearance from your physician to use this service? _________________________________
Please provide physician clearance (attached)
or provide signature for personal clearance:
Signature: _____________________________________
IN EVENT OF EMERGENCY
Who should we contact? ___________________________________________________________________________
Relation: _____________________________________________________________________________________________
Home Phone: ________________________
Cell Phone: ___________________________
E-mail: _______________________________________________________________________
Primary Physician: ________________________
Phone#: ___________________________
Should we call 911 if needed? __________________________________________________________
Should we perform CPR if needed? ______________________________________________________
HEALTH HISTORY
Please Circle
 Are you taking any of the following
medication?
 Nerve Pills
 Muscle Relaxers
 Insulin
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Blood thinners
Pain killers (including aspirin)
Tranquilizers
Stimulants
Others
Do you have or ever had any of the following diseases or conditions? Please provide
clearance if needed
Y N Heart Attack/Stroke
Y N Congenital Heart Defect
Y N Alcohol/Drug Abuse
Y N HIV/AIDs
Y N Frequent Neck Pain
Y N High/Low Blood
Pressure
Y N Severe /Frequent
Headache
Y N Fainting/Seizures/Epilepsy
Y N Diabetes/Tuberculosis
Y N Lower Back Problems
Y N Heart
Surgery/Pacemaker
Y N Mitral Valve Prolapse
Y N Venereal Disease
Y N Shingles
Y N Emphysema/Glaucoma
Y N Psychiatric Problems
Y N Sinus Problems
Y N Difficulty Breathing
Y N Artificial Bones/Joints
Y N Heart Murmur
Y N Artificial Valves
Y N Hepatitis
Y N Cancer
Y N Anemia
Y N Rheumatic Fever
Y N Ulcers/Colitis
Y N Asthma
Y N Chemotherapy
Y N Arthritis
DISCLAIMER
Pose Wellness, Staff, Technicians, and Health and Wellness Coach are not intended to diagnose, treat,
prevent or cure any disease or condition. It is not intended to substitute for the advice, treatment and/or
diagnosis of a qualified licensed professional. Trained health coaches may not make any medical
diagnoses, claims and/or substitute for your personal physician’s care.
Pose Wellness, Staff, Technicians, and Health and Wellness Coach do not provide a second opinion or in
any way attempt to alter the treatment plans or therapeutic goals/recommendations of your personal
physician. It is our role to partner with you to provide ongoing support and accountability as you create an
action plan to meet and maintain your health and wellness goals.
Acknowledged and Signed by: ____________________________________________________
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PRINT NAME
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DATE