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 Golf Experience: ________________________    Golf Handicap:________________________________________

Days/Holes of Golf per Week:___________________    Other Non-Golf Exercise:_______________________________

Golf Facility & Teacher: ____________________________________________________________________________________

Previous Injuries: __________________________________________________________________________________________

Please complete for Golf Fitness Evaluations

Time Commitment for Program: ___________________________________________________________________________

Available Equipment (bands, balls, weights, etc):___________________________________________________________

_____________________________________________________________________________________________________________            

Golf Fitness Goals: _________________________________________________________________________________________

_____________________________________________________________________________________________________________

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 golf 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: _________________________

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: _________________________