Medical Waiver | Functional PT Penrith

MEDICAL WAIVER

First Name

Last Name

Date of Birth

Phone

Address

Occupation

Subject

Message

Please explain any checked items from above

Medical Conditions: Please tick the following that apply

Has your doctor ever told you that you have aa heart condition or ever suffered a stroke?

Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?

Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?

If you have diabetes (type 1 or type 2), have you had trouble controlling your blood glucose in the last 3 months?

Do you have any undiagnosed muscle, bone or joint problems that could be made worse by participating in physical activity/exercise?

Do you have any other medical conditions that may make it dangerous for you to participate in physical activity/exercise?

None of the above apply to me

Please explain any checked items from above

Injuries: Please give me a brief description of your past or current injuries

Training: Please give me a brief description of your current training program

How did you hear about me?

Results: List 1 goal that you would realistically like to achieve in the next 6-12 months

Cancellation Policy: -I require a minimum of 24 hours notice if you wish to cancel or reschedule. Non-attendance to a booked appointment, with no reasonable explanation, will attract a 100% charge. This policy ensures other clients are able to access our services rather that being put on a waiting list or being turned away. Please tick the box to the left which confirms that you agree to this policy.

Media Consent: -By signing this form you consent to be in photo and video content created by me used for social media promotion and website content. (I will always consult you before publishing any content and discuss the option to anonymise your identity)

Waiver: Please agree by ticking the box to the left, that you understand to the following statement: "I understand that Steve Zekic is not able to provide me with medical advice with regard to my medical fitness. This information is used as a guideline to the limitations of my ability to exercise. I will not hold Steve Zekic liable in any way for injuries that many occur while I am training."

Date

THANKS FOR SUBMITTING