Attn: Donny Vanker
44191 Plymouth Oaks Blvd, Ste 600
Plymouth, MI 48170
Or fax to: 734-259-7104
This form must be filled out and submitted in order for you to be considered for a shceduled appointment in our Barwis Methods Injury Recovery program.
Please indicate area(s) where symptoms occur:
Was this a re-injury?
Have you been cleared by your physician for personal training? (Please attach a copy of your physician approval, we cannot put you on the list until we get a copy).
Please attach your latest progress note or letter from your physician indicating your current functional status.
Were you previously treated in physical therapy for this condition?
Please indicate what studies were performed:
REVIEW OF SYSTEMS (Check any/all symptoms you have experienced):
NOTE: All training payments are made up front and we will work with you in your efforts to get reimbursed. Rates may vary depending on who is training and the number of trainers required for your situation. We will contact you with this info prior to shceudling your training.
If you need financial assistance, please indicate below.**
I acknowledge that the information above and attached is complete and accurate.
Electronic Signature Agreement. By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by this Agreement's terms and conditions. You further agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action, or to otherwise provide Company instructions via Company's website or its affiliates, or in accessing or making any transaction regarding any agreement, acknowledgement, consent terms, disclosures or conditions constitutes your signature (hereafter referred to as "E-Signature"), acceptance and agreement as if actually signed by you in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting contract between you and Company. You also represent that you are authorized to enter into this Agreement.
Signature of Client or Legally Authorized Representative of Client
PHYSICIAN REFERRAL FORM - Please print the physician referral form for your doctor to complete and provide a copy to Barwis Methods upon your first visit.