Pre-Participation Physical Consent
Sign in to Google to save your progress. Learn more
Email *
Last Name 
First Name
A parent or legal guardian must complete and sign this consent form for persons under the age of 18.
Name of parent or legal guardian completing this form (if applicable)
Privacy Notice
I understand that Rise Up IV and Injection Therapy, LLC (aka Rise Up Health) will not share or disclose my personal health information unless
  • I Request it to be shared
  • for the purpose of continuity of care,
  • for obtaining payment,
  • to evaluate the quality of services provided,
  • and/or any administrative operations related to services or payment.
I also understand that I may request a copy of this consent and summary of services received.
I understand that communications may be required via email, phone, text, and/or video call. I understand that some forms of communications may be considered unsecured and that communicating through the patient portal is secure. I also understand that I can opt-out of text/email communications by notifying Rise Up Health.
Pre-Participation Physical Exam Consent

I hereby authorize Rise Up IV and Injection Therapy, LLC (aka Rise Up Health) providers to conduct pre-participation sports or other approved participation physical

I understand that this examination is designed to determine the difficulties, which may arise with athletic or other participation requiring physical exertion, and is not a complete physical examination designed to detect a rare or occult disease.

I hereby release Rise Up IV and Injection Therapy, LLC (aka Rise Up Health), as well as their staff, from any and all liability, which may arise from the administration of this physical examination, whether or not foreseen or unforeseen. If a health problem is found, I understand Rise Up IV and Injection Therapy, LLC (aka Rise Up Health) providers will inform me of any need for further medical attention. I have read and understand this acknowledgement form.

By selecting YES below, I certify that I am electronically signing this consent, which indicates that I understand, authorize, and consent. I certify my electronic signature below.
 *
Required
Signature of person receiving physical or legal guardian (if under the age of 18). 
(Type full name)
 *
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of Rise Up Health.

Does this form look suspicious? Report

Google Forms