Sports Performance Registration Form

Sports Performance Registration Form

Fill out the form carefully for registration
Patient Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
Phone Number*
Sport*
Level/Position*
Emergency Contact Information
Name*

First NameLast Name
Phone Number*
Relationship to Patient*
Photo Consent
I consent to Associates Physical Therapy using my photo and/or video of me on their website and social media page. At any time, I may revoke this consent.*

YesNo
Medical History
Previous medical injuries/conditions: *
Any current pain or injury? Currently receiving any treatments? *
GOALS FOR SPORTS PERFORMANCE*

Increase flexibilityIncrease power/explosivenessIncrease strengthEnduranceInjury preventionOther
Should be Empty:

Patient Information