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Intake Form Test

I authorize Viverant to release medical information, including billing details to this emergency contact.

Viverant Consent Terms & Conditions and Billing Agreement
I have read Viverant's Consent to Treat and Billing Agreement and agree to all terms and conditions
I have read Viverant's Privacy Practices Statement and understand my rights as they pertain to treatment at Viverant

Physical Activity Readiness Questionnaire (PAR-Q)

If you are planning to become more physically active than you are presently, please answer the questions below. If you are between the ages of 15 and 69, this PAR-Q will tell you if you should consult a doctor before you start. If you are over 69 years of age, check with your doctor.
Please click here to read the questionnaire. If you can answer NO to each of them, please check the box below:
  1. Has a doctor ever said you have a heart condition and should only do doctor-recommended physical activity?
  2. Do you feel pain in your chest when you do physical activity?
  3. In the past month, have you had chest pain when you were not doing physical activity?
  4. Do you lose your balance because of dizziness or do you ever lose consciousness?
  5. Do you have a bone or joint problem that could be made worse by a change in your physical activity?
  6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
  7. Do you know of any other reason why you should not do physical activity?
If you answered yes to one or more questions: Talk with your doctor BEFORE you start becoming more physically active and BEFORE you have a fitness assessment. If you proceed with physical activity, you do so at your own accord knowing any possible inherent risk.

I have read, understood, and answered NO to the 7 Par-Q questions above.
Attach ID (Drivers' License, other)
Attach front of insurance card
Attach back of insurance card
Attach Physician Referral/Orders
Attach X-Ray/Imaging

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