ࡱ> 8:7q` bjbjqPqP .*::$hhhhhhh|8,|'))))))$~h`MhMhhbdhh'':w,hh OT 'x0RF F F h("1YMMvX||| @D|||@|||hhhhhh Facility Policy PATIENTS ARE TO BE AWARE OF THEIR INSURANCE COVERAGE PRIOR TO RECEIVING SEVICES. (IF YOU NEED ASSITANCE WITH THIS PLEASE INFORM THE FRONT OFFICE) COPY(S) OF INSURANCE COVERAGE AND I.D. ARE REQUIRED UPON ADMISSION. COPAYS OR COINSURANCES ARE TO BE PAID PRIOR EACH TREATMENT SESSION LCR ACCEPTS CHECKS WITH PROPER I.D. A $25 FEE WILL BE APPLIED FOR RETURNED CHECKS ALL BALANCES ARE DUE WITHIN 30 DAYS UNLESS OTHER PAYMENT ARRANGEMENTS HAVE BEEN MADE WITH THE BILLING DEPARTMENT. STREET SHOES ARE NOT PERMITTED IN THE GYM AND POOL AREAS. SHOES SHOULD BE CLEAN AND DRY. FOOD AND DRINK ARE NOT PERMITTED IN THE GYM AND POOL AREAS. PATIENTS HAVE TO SIGN ALL LCR ADMISSION FORMS PRIOR TO THEIR FIRST TREATMENT. PATIENTS ARE TO CALL 24 HOURS IN ADVANCE WHEN CANCELING AN APPOINTMENT TO AVOID A $25 CHARGE. ALL PATIENTS UNDER THE AGE OF 18 HAVE TO BE ACCOMPANIED BY A PARENT/GUARDIAN UNLESS OTHER ARRANGEMENTS HAVE BEEN MADE. By signing below you agree that you have read the above terms and agree to comply with the LCR facility policies. PATIENT SIGNATURE_________________________________DATE____________ PARENT/GUARDIAN SIGNATURE____________________________RELATIONSHIP________ Lakeside Rehabs Wellness Payment Agreement Clients Name:___________________________________ Phone #_______________ \Address:_______________________________________________________ DOB:___/___/___ Senior (over 65): Yes____ No____ Wellness Program Package (Select One): _____Gym Only _____Pool Only _____Pool & Gym ____Hot Tub Only ____Pool and Hot Tub ____Pool, Hot Tub and Gym Package will be paid (Select One): _____Per Visit ____Punch Card Wellness Policy: ALL packages/visits must be PAID IN ADVANCE. Approval must be obtained by a physician prior to the start of the program if applicable. A fitness evaluation will be required to start your program (included in the package) and may be updated throughout your program. An orientation will be required in order to show the most effective and proper use to the equipment and/or facilities. This will be provided at the time of evaluation. Orientation has to be attended at scheduled time. No one will be admitted into the pool area without Lakeside Rehab personnel present. All programs will be available at the posted schedule times (subject to change at any time). Delays in getting started for any reason will not interfere with the appointed ending time. Personal Waiver: By signing below I acknowledge that I have been informed of the need to obtain a physicians approval prior to beginning any exercise program. I fully understand that these programs that I choose to participate in are completely voluntary. I accept full responsibility for any injury or health complications that may occur during my time participating in the programs. I hold Lakeside Rehab (Officers, Employees and Instructors) harmless of any responsibility. Participants Signature ___________________________ Date______________ Lakeside Staff Signature __________________________ Date______________ WELLNESS PROGRAM QUESTIONAIRE NAME:_____________________________________PHONE:___________ ADDRESS:____________________________________________________ CITY:_________________STATE:____ZIP:______D/O/B______AGE___ Are you currently under medical care for any significant problems? _______ If yes, please explain: ____________________________________________________________ Do you presently have or have had in the past any of the following conditions: Diabetes Yes No Allergies Yes No High Blood Pressure Yes No Pregnancy Yes No Heart Disease Yes No Previous Surgery Yes No Heart Attack Yes No Headaches Yes No Pacemaker Yes No Migraines Yes No Seizures Yes No Kidney Problems Yes No Metal Implants Yes No Nervous Disorders Yes No Circulatory Disorders Yes No Hernia Yes No Hepatitis B Yes No If yes on any of the above, please give approximate date and brief description of condition(s): _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ Please list any medications you are presently taking: ____________________________________________________________ _____________________________________________________________ By signing below you state that all the above information was given to the best of your knowledge. Signature:____________________________________ Date:____________     Version date: 2/13/09   , - 1 7 8 o q + F J K M [   8 =a۷߬zhd5>*CJ\aJhd5CJ\aJhdCJaJhdCJ$aJ$hd5CJ$\aJ$hDTehdCJaJhdCJaJhhd5>*hhd>*hRahd5>*hd hDTehdhDTehd5 hd5hdhd5CJ(aJ(0, -  L M 7 8 $ % h gdd & Fgddh^hgdd $h^ha$gddh i - . p q =>bc & Fh^h`gdd$a$gddgddgdd%&'ceij͹͇hZjhZUhdhdB*CJaJphhdB*CJaJphhdhdB*CJ$aJ$ph&hdhd5>*B*CJ$\aJ$phhdhdhdB*phhdB*phhd5CJ\aJhd>*CJaJhdCJaJ&|mno&'de $7$8$H$a$gdd 7$8$H$gddgddgdd & Fh^h`gdd.#Qw2Oijgdd 7$8$H$gddgdd$a$gdZ ,1h/ =!"#$% @`@ dNormalCJ_HaJmH sH tH DA@D Default Paragraph FontRi@R  Table Normal4 l4a (k@(No List4`4 dHeader  !4 `4 dFooter  !VoV dDefault 7$8$H$!B*CJ_HaJmH phsH tH *,-LM78$%hi-.pq=>bc| m n o     & ' d e . #Qw2Oij00 00 00 00 00 00 00 00 00 00 0 00000000000000000000000000 0 0 0 0 0 00000000000000000000000000000000000000000000000I00I00@0I00@0I00@0I00@0@0I00 m  2OiK00({ K00K00r =%,-K00K00{ K00K00K00K00 ###& h 8@0(  B S  ?zQDHzQ  9*urn:schemas-microsoft-com:office:smarttagsplace ftv + - l n su33333333bcvm o   & ' c e ij fb0.808^8`0o(. ^`hH. pLp^p`LhH. @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.b 聜e        du3EFZ@P@Unknowngz Times New RomanTimes New Roman5Symbol3& z Arial"1h%J.J    !4d2QHX ?d2Facility PolicyAshimaAshima  Oh+'0t  0 < HT\dlFacility PolicyAshimaNormalAshima1Microsoft Office Word@vA@'@\i՜.+,0 hp   Lakeside Rehab   Facility Policy Title  !"#$%&()*+,-.01234569Root Entry Fpi;1TableZ WordDocument.*SummaryInformation('DocumentSummaryInformation8/CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q