Medical Condition Disclosures Redirect

As a course participant, you ("participant", "course participant", "attendee") understand that you are responsible for disclosing to the Academy of Pelvic Health Physical Therapy ('Academy," "APTA Pelvic Health") any relevant physical, emotional, and medical conditions, limitations, and/or sensitivities that may impact your participation in an upcoming course ("Event", "Course"). By completing this form, you consent to the Academy sharing your disclosed health information with Academy's staff and contracted faculty in preparation for the upcoming course.

If the course requires participants to participate as both "patients" and "clinicians" in lab activities and you are not able to participate as the "patient," you will additionally need to provide your own live medical model to stand in for you during the lab activities. Review the Medical Model Guidelines. If the participant is bringing a medical model, the participant must have their model complete the Medical Model Liability Waiver Form form at least 7 days prior to the course.

THIS FORM IS ONLY FOR THOSE WHO HAVE MEDICAL CONDITIONS TO DISCLOSE.

IF YOU HAVE NO MEDICAL CONDITIONS TO DISCLOSE, PLEASE DO NOT FILL OUT THIS FORM.

Click Here to Proceed to the Form

Select your course*

If you do not see your course in the drop-down above, please type the name of the course below.

Course Participant Full Name*

First NameLast Name

Course Participant Email Address*

example@example.com

Select Type*

PregnancyOtherBoth

List any relevant physical, emotional, and medical conditions, limitations, and/or sensitivities that may impact your participation in the course. Please ensure that you fully and accurately disclose about your health that is relevant to your participation.

Please select one*

I WILL be able to fully participate in the lab activities and will NOT bring a modelI WILL NOT be able to participate in the lab activities but WILL bring a medical model

MODEL MODEL USAGE INSTRUCTIONS: Based on your response, it looks like you have decided to bring a Medical Model! Please take a moment to review our Medical Model Use Guidelines and make sure your medical model completes the Medical Model Consent & Liability Waiver Form. Save these links for your records.

Emergency Contact's Full Name, Relationship, Phone Number, Email Address*

i.e. Joanna Smith, Mother, XXX-XXX-XXXX, joanna@gmail.com

Upload Signed Physician's Note

If you plan to fully participate in the course and its lab activities in spite of your disclosed medical conditions, please consult with your physician in regard to whether they believe it is safe for you to participate fully in this course. We recommend that you share the course description with your physician and we require you to provide a signed note from your physician permitting you to participate.

Healthcare Provider's Full Legal Name

First NameLast Name

Healthcare Provider Job Title

i.e. Obstetrician, Urologist, Primary Care Physician

Healthcare Provider's Email Address

example@example.com

Physician's Note with Signature

By filling out this form, you affirm that you have fully and accurately answered all questions about your health, and that you have disclosed all information concerning your health that is relevant to your participation in the Event via the designated Medical Disclosures Form.

Sign below*

Medical Conditions Disclosure Form