Personal Details

Medical History

Please answer the following health-related questions as honestly as possible and with either “yes” or “no”. If you have answered any questions with “yes”, please explain these in more detail in the end section titled “Personal Medical History“.

If you have any concerns about your fitness or health, you should seek appropriate medical advice from a relevant professional medical or other adviser before attending a Training Session, and where necessary, you must obtain clearance from a relevant professional medical or other adviser before booking or attending any Training Session. We cannot and do not provide any such advice or clearance. Advice provided by our instructors at no time constitutes medical advice in substitute for advice provided by a medical professional.

Emergency Contact

Liability Declaration

I declare that the information that I have supplied is accurate to the best of my knowledge and will be treated as confidential by FitXEMS and as such will not be released or revealed to any other persons without a client’s written consent.

I hereby agree I will not be under the influence of any drugs, alcohol or other mind altering substances which may place me under any harm during a training session with FitXEMS.

I recognise that exercise is not without some risk and known dangers, which commonly include sprains, strains, dizziness, fainting, discomfort in breathing, abnormal blood pressure, irregular heartbeats and in very rare instances heart attack or death.

I hereby understand, acknowledge and accept these risks and known dangers and certify that I have voluntarily elected myself to participate in a health and fitness evaluation and/or exercise program. I agree to be bound to the terms and conditions as set out by FitXEMS.

I hereby release to the full extent permitted by law, FitXEMS from all claims and demands of every kind with respect to any accident, damage, injury, loss to person and property, pain and suffering however caused.  This includes health and fitness assessments, personal training and personal exercise using FitXEMS equipment and any other form of exercise coordinated by FitXEMS, their staff, contractors, instructors or agents.  I wholly indemnify FitXEMS from and against all actions, suits, claims, costs, damages and expenses to which FitXEMS is or may be liable. 

EMS (Electro Muscle Stimulation) training must be approached cautiously. Failure to do so, places you at risk of a potentially life threatening condition, known as ‘Rhabdomyolysis’ caused by muscle damage and seriously affecting internal organs. EMS can cause Rhabdomyolysis. Brown urine, complete muscle weakness and/or swelling of joints are warning signs and you must seek medical assistance IMMEDIATELY. 

I acknowledge and understand that I have voluntarily chosen to participate in training activities provided by FitXEMS and understand there are inherent risks in all aspects of physical training and I acknowledge that I have been informed of the possible strenuous nature of the training and the potential for undesirable physiological results including, but not limited to, abnormal blood pressure, muscle soreness, fainting, heart attack and/or death. 

I warrant that I do not suffer from any medical condition that may affect my ability to participate safely in strenuous exercise. I also acknowledge that I have been specifically warned about the medical condition “Rhabdomyolysis” and accordingly I have been advised to limit my effort in order to minimise the risks associated with this condition. I understand that should I feel lightheaded, faint, dizzy, nauseated, or experience pain or discomfort, I am to stop the activity and inform my trainer. I give any employee of FitXEMS permission to seek emergency medical services for me should I become injured or ill with the understanding that I am responsible for any expenses incurred. 

Use of picture(s)/film/likeness: I agree to allow the gym, its agents, officers, principals, employees and volunteers to use picture(s), film and/or likeness of me. In the event I choose not to allow the use of the same for said purpose, I agree that I must inform the gym of this in writing. I HAVE READ AND UNDERSTOOD THIS AGREEMENT AND I AM AWARE THAT BY SIGNING THIS “INFORMED CONSENT FORM” I AM WAIVING CERTAIN LEGAL RIGHTS (INCLUDING THE RIGHT TO SUE) WHICH I OR MY HEIRS, NEXT OF KIN, EXECUTOR, ADMINISTERS AND ASSIGNS MAY HAVE AGAINST THE RELEASEES. ANY QUESTIONS I HAD WERE ANSWERED TO MY FULL SATISFACTION. 

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