Name: __________________________________________________       Date of Birth: _________________________________

Street Address: _____________________________________________________________________________________________

City: ________________________________________________    State: __________    Zip Code:_________________________

Home Phone: _____________________________________    Cell Phone: ___________________________________________

Email Address: _____________________________________________________________________________________________

Emergency Contact: __________________________________________    Phone: ___________________________________

Relationship to Patient/Client: _____________________________________________________________________________

Primary Care Doctor: ________________________________________    Phone: ____________________________________

Specialist Doctor: _____________________________________________    Phone: ___________________________________

Years of Dance Experience: _____________________ Types of Dance: __________________________________________
Days/Hours of Dance per Week: ________________ Other Non-Dance Exercise: ______________________________
Dance School/Facility & Teacher: ___________________________________________________________________________
Previous Dance Injuries: ___________________________________________________________________________________
Please complete for Dance Fitness Evaluations
Time Commitment for Program: ___________________________________________________________________________
Available Equipment (bands, balls, weights, etc): ___________________________________________________________
_____________________________________________________________________________________________________________
Goals for Program: _________________________________________________________________________________________
_____________________________________________________________________________________________________________
How did you hear about Magna Physical Therapy? _________________________________________________________
POLICIES:
􀁸 It is our policy that services be paid for at the time of or before services are rendered. Payments are
non-refundable.
􀁸 Magna Physical Therapy will accept the following forms of payment for services provided: cash,
personal check, credit or debit card (Visa, MasterCard, and Discover).
􀁸 In the case that you are not able to attend a dance fitness, training, or evaluation session, we kindly ask
that you call our office to cancel or reschedule 24 hours in advance.
I, the undersigned, have reviewed the above policies and do hereby agree to abide by them
to the best of my abilities.
Client/Guardian Signature: ______________________________________________ Date: ________________________
2
Name: _______________________________________________ Date of Birth: ___________________________________
EXERCISE CONSENT FORM
I wish to join/be treated by Magna Physical Therapy & Sports Medicine Center, LLC to improve my fitness
level. I understand that I will need to complete a medical history form prior to participating, which may
indicate that I should not participate in a fitness program or that my program may need to be altered. I
understand that withholding information about my health may result in an incorrect exercise prescription,
which may cause harm to me.
I understand that if I have certain pre-existing medical problems, or if medical concerns develop during the
course of my participation, the Magna Physical Therapy & Sports Medicine Center, LLC staff may consult
my physician and may request his/her consent for my participation. I understand that the staff has the
right to address concerns about my health with my physician and may ask to temporarily discontinue or
modify my exercise program until my physician evaluates my condition and provides recommendations for
participation. I understand the staff will review all available information to develop a safe and effective
exercise program for me. All information received or generated about me is strictly confidential.
The exercises are designed to place a gradually increasing workload as tolerated on my cardiovascular and
musculoskeletal system, thereby improving its function. I understand the risks of participating in an
exercise program. I understand that the Magna Physical Therapy & Sports Medicine Center, LLC staff will
take all measures to avoid an adverse response to exercise. I understand that providing the staff with
current information about changes in my health, which includes any illness or symptoms I experience in
the performance center or at home, is essential for the staff to determine if my exercise program needs any
modifications. I understand that if I do not provide such information to the staff, I may be putting myself at
risk for injury or serious medical problems.
I understand that I am required to respect the rights of all participants and staff members involved with the
Magna Physical Therapy & Sports Medicine Center.
I acknowledge that no guarantees can be made to me as a result of my participation in the program. I
understand that no assurance can be given to me that participation in a fitness program will increase my
functional/athletic capacity, improve my blood sugar and blood pressure, or assist in weight loss.
I hereby release Magna Physical Therapy & Sports Medicine Center, LLC, its affiliated entities,
employees, trustees, and their respective representatives and agents from all claims, liabilities, and
causes of action arising or associated with my participation in this program. I have read the
foregoing or it has been read to me, and I understand its contents and significance.

 

Client/Guardian Signature: ______________________________________________    Date: _________________________

 

MPT Witness Signature: _________________________________________________    Date: _________________________