1:1 Performance Therapy | Rehabilitation Sign Up

Athlete [Patient] First Name *

Athlete [Patient] Last Name *

Athlete [Patient] Phone *

Athlete [Patient] Email *

Athlete [Patient] Date of Birth *

If under 18, enter your parent / guardian information

Parent / Guardian Full Name *

Parent / Guardian Phone *

Parent / Guardian Email *

Street Address

City

State

Referred by *

What School do you Attend? *

List the Sport(s) you Participate In *

What is Your Current Level of Activity? *

What are your Goals with Rehab? *

Medical Information

Current Surgery or Injury *

Other Relevant Surgical or Injury History *

Current Injuries or Regions of Pain? *

Have you been evaluated by a physician or physical therapist for your current issue? *

Physician

Physical Therapist

Other Healthcare Professional

I have not been previously evaluated for current condition

Have you ever been Dry Needled? *

Yes

If you selected an option below, please list the name of the professional that you were evaluated by and their credentials: *

Additional Information you Would Like for Us to Know *

Emergency Contact Name & Relation *

Emergency Contact Phone *

Wavier and Release, Assumption of Risk Agreement and Parental Indemnification Agreement

I agree to the above Waiver and Release, Assumption of Risk Agreement and Parental Indemnification Agreement

Cancellation Policy

At Elevate Sports Performance, we strive to provide the highest level of service to our clients. To ensure a fair and efficient scheduling process, we have implemented the following cancellation policy: 1. Cancellation Notice: Clients must provide a minimum of 48 hours' notice for any cancellation or rescheduling of sessions. 2. Charges for Late Cancellations: If a cancellation is made less than 48 hours before the scheduled session, the client will be charged the full price of the session. 3. Notification Method: Cancellations should be communicated via phone call, text, or email directly to our administrator AND performance rehabilitation specialist. 4. Exceptions: We understand that emergencies can happen. In such cases, please contact us as soon as possible to discuss your situation. Exceptions to this policy may be made at the discretion of the Elevate team. *By scheduling a session with us, you acknowledge and agree to adhere to this cancellation policy. Thank you for your understanding and support. For questions or further clarification, please feel free to reach out to our Administrator Anne! *

I understand and accept the 48 hour notice for training cancellations policy

Consent for Transational Messaging

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

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