Well-Being Patient Registration Form - IN PERSON CLASS ($599)

Thank you for taking interest in the 12-week Florida Medical Clinic Well-Being Program. In order to get you registered, please answer the questions below. We hope that you are as excited as we are to begin this transformation journey together!  Please note that your registration is NOT complete until payment is made. 

This form is for non FMC Employees.  If you are a FMC Employee interested in registering, please contact Kelly Matthew (kmatthew@floridamedicalclinic.com)

If you have any questions or concerns, please reach out to wellbeing@floridamedicalclinic.com or call (813) 849-1656 to speak with someone from the  Well-Being Team. 

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* 1. First and Last Name

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* 2. Please enter your Date of Birth

Date

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* 3. What is your preferred email address?

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* 4. What is your preferred phone number?

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* 5. What is your street address?

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* 6. How did you hear about the Well-Being program?

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* 7. Are you signing up with a friend or partner? If so, please let us know who is joining you.

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* 8. Please check all that apply.
I am under the care of a physician for the following:

Those under a physician's care will be required to have their physician complete a program release form.  Form will be supplied to you or you may email wellbeing@floridamedicalclinic.com to request a form.

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* 9. If you are a diabetic, please list all medication you are currently taking.

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* 10. Who is your Primary Care Physician?

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* 11. Are you a repeat participant?

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* 12. Health & Fitness Liability Waiver/Informed Consent Form
Well-Being:  A Tribe Planted with Purpose
I, ________________________________, have voluntarily decided to participate in Well-Being: A Tribe Planted with Purpose, a 12-week wellness transformation program, including a fitness program, offered through Florida Medical Clinic. I hereby assert that my participation is completely voluntary, and I knowingly assume all risks of participation. 
I have been advised that an examination by a physician should be obtained by anyone prior to commencing this program or initiating a substantial change in the amount of regular physical activity performed. I am aware that the nutritional education and meal planning will result in a significant change to my current diet.  This change in my diet may reduce both my blood pressure and blood glucose levels, therefore, reducing the need of certain medications if I have high blood pressure and/or diabetes. If I currently have high blood pressure and /or diabetes, I am aware close follow up with my primary care physician and/or endocrinologist will be needed. If I have chosen not to obtain a physician’s consent prior to beginning this program, I hereby agree that I am doing so solely at my own risk.  I understand that it is my sole responsibility to participate in exercises that are appropriate for the current status of my health.  If I have any questions or concerns about whether or not a particular activity is appropriate to my current health status, I understand it is my responsibility to ask my doctor if this activity is appropriate before I participate in such activity.
I understand that this program is not medically supervised, and exercise activities are led by independent fitness instructors or other program participants who may or may not be employees or agents of Florida Medical Clinic.  I agree not to hold Florida Medical Clinic and/or Well-Being instructors responsible for any injury or complication as a result of the program.  In the event of injury, accident and/or illness, regardless of the cause, during this activity or event I consent to receive medical treatment, but I acknowledge that FMC or the Well-Being instructors will not be responsible for that medical treatment. I knowingly assume all risks of participation. I recognize that the program may involve strenuous physical activity including, but not limited to, muscle strength and endurance training, cardiovascular conditioning and training, and other various fitness activities.
I understand that the Florida Medical Clinic may, in its sole discretion and at any time, revoke my enrollment in the Program. I understand that any exercise or fitness activity involves a risk of injury, as well as abnormal changes in blood pressure, fainting, and a remote risk of heart attack, stroke, other serious disability or death. I understand the dietary changes may result in changes in blood pressure, blood glucose levels, hydration, and electrolyte requirements.  I am accepting such risks and volunteering to participate with full understanding of the dangers involved. In consideration of my participation in this program, I hereby waive and release Florida Medical Clinic, the Well-Being instructors, and its successors and assigns, from any and all claims, costs, liability and expense for any injury, loss or damage whether known, anticipated or unanticipated arising from my voluntary participation and enrollment. I acknowledge (By entering name below) that I have thoroughly read this form in its entirety and fully understand it.  I understand that it contains a release of liability.  By signing this document, I am waiving certain rights I or my successors might have to bring a legal action or assert a claim against Florida Medical Clinic or the Well-Being instructors.  I understand there are no refunds for this program.
Pregnant or Type 1 Diabetic- ONLY permissible to participate in the low carb track

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* 13. Pre-program measurements will be conducted prior to the start of class.  A team member will reach out to you to schedule this appointment after your registration has been completed, including payment. If you need to set up a payment plan, please contact Kelly Matthew at 813-849-1656.

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