Pre-Screen Permission Form

Gymnasts Full Name(required)

Parent/Guardians Full Name (required)

Parent/Guardian Email (required)

Gymnasts date of birth (required)

Street Address (required)

Suburb (required)

Post Code (required)

Postal Address (If different from above)

Parent/Guardian Home phone:

Parent/Guardian Mobile number: (required)

Areas of concern (required):

Please tick the boxes if the Gymnast (or has in the past), suffers from any of the following:

Cancer
Heart Condition
Epilepsy
High/low blood pressure
Circulation/Vascular problem
Other Lung conditions
Diabetes
Thyroid condition
Neurological condition
Arthritis
Osteoporosis
Depression
Stroke
Skin conditions (including allergies to tapes)
Do you have a pacemaker

If any of the above are ticked, please provide further details below:

Is the Gymnastic currently taking medications (Please list or write "none") (required):

I authorise Physionorth's Physiotherapists to complete a pre-screen assessment on my child

I hereby authorise Physionorth to discuss the findings of the assessment with my child's gymnastics coach

I understand my email address will be added to the Physionorth database for access to the Exercise App, Online bookings and for correspondence from Physionorth staff regarding results from your child's assessment - see privacy policy

Privacy Policy: All client details are stored confidentially with your clinical notes and not disclosed to anybody outside Physionorth. Email addresses added to the Physionorth database for access to the Exercise App and Online Bookings may also occasionally receive material at the mailing or email address listed in this form from Physionorth regarding promotions, discounts, updates, products & services.