Empire Performance PT

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  • About Us
    • Meet The Team >
      • Dr. Tony Tanzi, PT, DPT, CSCS
      • Dr. Kyle PT, DPT
      • Dr. Matthew PT, DPT
      • Jeffrey Mansfield, PT, MSPT
      • Alana PTA
  • Physical Therapy
    • Back Pain
    • Knee Pain
    • Shoulder Pain
    • Ankle Pain
  • Sports Rehabilitation
  • Join Our Team!
  • Blog
  • 5 Minute Friday
  • Contact Us
  • Home
  • About Us
    • Meet The Team >
      • Dr. Tony Tanzi, PT, DPT, CSCS
      • Dr. Kyle PT, DPT
      • Dr. Matthew PT, DPT
      • Jeffrey Mansfield, PT, MSPT
      • Alana PTA
  • Physical Therapy
    • Back Pain
    • Knee Pain
    • Shoulder Pain
    • Ankle Pain
  • Sports Rehabilitation
  • Join Our Team!
  • Blog
  • 5 Minute Friday
  • Contact Us

Please answer all questions accurately and honestly to allow us to fully determine your individual needs.

    Fitness Questionnaire

    Please list your desired fitness goals:
    BUYER ACKNOWLEDGMENT AND ASSUMPTION OF RISK AND FULL RELEASE FROM LIABILITY OF EMPIRE PERFORMANCE PT.  BUYER ACKNOWLEDGES THESE PHYSICAL ACTIVITIES INVOLVES THE INHERENT RISK OF PHYSICAL INJURIES OR OTHER DAMAGES, INCLUDING, BUT NOT LIMITED TO, HEART ATTACKS, MUSCLE STRAINS, PULLS OR TEARS, BROKEN BONES, SHIN SPLINTS, HEART PROSTRATION, KNEE/LOWER BACK/FOOT INJURIES AND ANY OTHER ILLNESS, SORENESS, OR INJURY HOWEVER CAUSED, OCCURRING DURING OR AFTER BUYER’S PARTICIPATION IN THE PHYSICAL ACTIVITIES. BUYER FURTHER ACKNOWLEDGES THAT SUCH RISKS INCLUDE, BUT ARE NOT LIMITED TO, INJURIES CAUSED BY THE NEGLIGENCE OF AN INSTRUCTOR OR OTHER PERSON, DEFECTIVE OR IMPROPERLY USED EQUIPMENT, OVER-EXERTION OF A BUYER, SLIP AND FALL BY BUYER, OR AN UNKNOWN HEALTH PROBLEM OF BUYER. BUYER AGREES TO ASSUME ALL RISK AND RESPONSIBILITY INVOLVED WITH PARTICIPATION IN THE PHYSICAL ACTIVITIES, BUYER AFFIRMS THAT BUYER IS IN GOOD PHYSICAL CONDITION AND DOES NOT SUFFER FROM ANY DISABILITY THAT WOULD PREVENT OR LIMIT PARTICIPATION IN THE PHYSICAL ACTIVITIES. BUYER ACKNOWLEDGES PARTICIPATION WILL BE PHYSICALLY AND MENTALLY CHALLENGING, AND BUYER AGREES THAT IT IS THE RESPONSIBILITY OF BUYER TO SEEK COMPETENT MEDICAL OR OTHER PROFESSIONAL ADVICE, REGARDING ANY CONCERNS OR QUESTIONS INVOLVED WITH THE ABILITY OF BUYER TO TAKE PART IN EMPIRE PERFORMANCE PT PHYSICAL ACTIVITIES. BY SIGNING THIS AGREEMENT, BUYER ASSERTS THAT HE OR SHE IS CAPABLE OF PARTICIPATING IN THE PHYSICAL ACTIVITIES. BUYER AGREES TO ASSUME ALL RISK AND RESPONSIBILITY FOR NOT EXCEEDING HIS OR HER PHYSICAL LIMITS.        
    Assumption Of Risk and Liability Release Form
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