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URMC / Orthopaedics and Rehabilitation / Patient Care / Appointment Request / Specialty Programs Registration Form

Specialty Programs Registration Form

Athlete's Information
Gender
 
 

If under the age of 18 years old, please provide the name(s) of your Parent(s).

 
 
 
 
 
 
 
 
 

Use ctrl+click to select any/all that apply

 
 
 
 
 
 
 
 
 
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Emergency Contact Information

 
 
 
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Primary Care Physician (only if referral needed)

 
 
 
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Athletic Performance Training Services

Testing Options

Movement Analysis

$75.00
$0.00

VO2 Analysis and Fitness Testing

VO2 Analysis

$150.00
$0.00

Resting Metabolic Rate (RMR) Testing

$150.00
$0.00

Athletic Performance Sessions

24 Sessions

$408.00
$0.00

36 Sessions

$540.00
$0.00

48 Sessions

$624.00
$0.00

Trial 5 Sessions

$160.00
$0.00

1 Session

$32.00
$0.00

A La Carte Sessions

Sports Nutrition Initial Evaluation

$75.00
$0.00

Sports Nutrition Follow-Up$35.00 per session. Number of sessions =

$35.00
$0.00

Mental Skills Initial Evaluation

$50.00
$0.00

Mental Skills Follow-Up$35.00 per session. Number of sessions =

$35.00
$0.00

Custom (Team) Training ProgramDollar amount from quote = $

QUOTE
$0.00

Total: $0.00