First Name *

Last Name *

Email *

Phone *

Date of birth *

Address

Street Address

Country

State

City

Postal code

Emergency Contact Name *

Emergency Phone Number *

Today's Date *

I agree to receive text messages from this business about my appointments.

How did you hear about our practice? *

What is the primary issue or problem we can help you with? *

What is the secondary issue or problem we can help you with?

What are you unable to do or currently having a hard time with as a result of the problem? *

When did the symptoms begin (month/year)? *

What other types of treatment have you had for this problem? *

Please Check Any/All That Apply to You

I've had spinal fusion surgery

I have been in a car accident/traumatic event in the last 6 months

I am currently taking blood thinners

I have a blood clotting disorder

I have had a stroke in the last 6 months

I have frequent dizzy spells

I have a metal allergy

I bruise easily

List past medical history and date of occurrence(s). Include surgeries, accidents, and other trauma(s).

List all medications you are currently taking and what the medication is used for:

Is there a chance you may be pregnant at this time? *

Please list the activities that you would like to be able to do as a result of physical therapy: (i.e. sleep, running, lifting weights, etc...) *

Informed Consent

1. Consent for Treatment & Acknowledgment of Services

I understand that Skilled Fitness & Therapy provides physical therapy, injury prevention, strength training, and recovery services. I consent to receive care, which may include but is not limited to manual therapy, cupping, muscle scraping, corrective exercises, strength training, and recovery techniques. I acknowledge that results may vary, and no guarantees of specific outcomes have been made.

2. Assumption of Risk & Liability Waiver

I understand that physical therapy, strength training, and recovery treatments involve inherent risks, including but not limited to muscle soreness, fatigue, injury, or aggravation of pre-existing conditions. I voluntarily assume all risks associated with participating in therapy, treatment, and exercise programming. I release, waive, and discharge Skilled Fitness & Therapy, its employees, agents, and affiliates from any liability, claims, demands, or causes of action that may arise from my participation in services.

3. Athlete-Specific Waiver (If Applicable)

I acknowledge that sports-related rehab and performance training require physical exertion and carry the potential for injury. I confirm that I am physically capable of participating and have disclosed any existing medical conditions. I accept full responsibility for my participation and waive any claims against Skilled Fitness & Therapy related to injury or performance outcomes.

4. Payment, Cancellation & Refund Policy

I acknowledge that all services must be paid in full before receiving treatment. Any cancellations or reschedules must be made at least 12 hours in advance, or a $20 late cancellation fee will apply. No refunds will be issued for services rendered or prepaid packages.

5. Recurring Payments & Memberships

For any payment plans or memberships set up with recurring payments, I acknowledge that payments will continue to be charged until the designated contract period ends. Early cancellations are not permitted unless otherwise stated in the membership agreement. By enrolling in a subscription-based service, I agree to the full financial commitment of the plan selected.

6. Media Release & Marketing Consent

I grant Skilled Fitness & Therapy permission to use my photographs, videos, or testimonials for marketing, social media, and educational purposes. I understand that no compensation will be provided, and I can revoke this consent in writing at any time.

7. Agreement & Understanding

By signing this form, I confirm that I have read, understood, and agree to all terms outlined above. I acknowledge that I have been given the opportunity to ask questions and voluntarily consent to receive services under these terms.

Please make a selection and sign below *

I consent to any techniques that may be used by Physical Therapist

I DO NOT consent to any manual techniques that may be used

Signature *

Clear

Payment Agreement

I confirm that I have read and understand that Skilled Fitness & Therapy is an out of network facility that requires payment on day of service. I understand that these services may be covered by my insurance with an in-network provider. *

I understand that I am seeing an out of network provider and I am responsible for submitting claims to my insurance

I DO NOT agree with this payment plan and would like to seek treatment from an in-network provider

Signature *

Clear

What to Wear to your appointment:

-Athletic clothing or clothing you feel comfortable in performing exercises

-Clothing that will allow proper showing of any wounds, incisions, scars, etc.

-Appropriate closed toe shoes for safety around weights

-If expecting to perform manual techniques to shoulders or back wear attire that will allow removal of shirt