Welcome to NAKOA Fitness and Physical Therapy. Please fill out and submit your application. Please make sure to provide an answer to each question, even if a question is not applicable (n/a). Once completed, our team will review it and contact you to schedule your first visit.
Who is the NAKOA Member who referred you? Or else, how did you hear about us?
(We would like to reward them through our Member Referral Program!)
Would you like to subscribe to our NAKOA Newsletter? It's filled with amazingness!
What are you interested in?
Private Coaching Group Training Physical Therapy Nutrition Massage
Your background.... Your interests.
Please tell us a little about yourself so we can better serve you.
How would you describe your current fitness level?
Grasshopper (show me the way to greatness!)
Karate Kid (looking for a Mr. Miyagi to fine tune my skills)
Chuck Norris (I invented fitness)
What are your goals and main focus for your fitness program?
General Health Information
To the best of your knowledge, do you have (or have you had)?
Heart Disease/Heart Attack
Women: Are you hosting a baby? (pregnant)
Are you seeing a medical provider for any other outstanding medical issues that we should know about before we start?
If yes, please explain:
Please list any allergies you may have. If you don't have allergies, please answer none.
Please list any surgeries you may have had. If you have not had any surgeries, please answer none.
Health Risk Markers
Now that we know who you are, please tell us about how you feel.
I feel stressed:
Always. In fact, this application is stressing me out
Sometimes. Like when I look at gas prices going up.
Never. I am like water, everything just flows.
I feel productive at work:
Always. I always find tasks to complete!
Sometimes. Whenever my boss is paying attention.
Never. Define productive….
During a typical month I take one sick day:
Obviously. I still get paid, don't I?
No, my immune system is impenetrable!
Do you have low back pain?
Yes - Sharp, stabbing, mind numbing pains. All. The. Time.
Yes - dull and achey, but I choose to ignore it most of the time
Nope! I'm one of the lucky ones!
Do you currently smoke cigarettes? (No judgement!)
Do you currently have hypertension? (high blood pressure, specifically above 140/90)
Yes, it's high
Yes, it's high, but I take beta blockers to keep it down
Nope, I got it under control
Are you using any medication per your MD's recommendation?
If yes, please list them here:
Have you had an injury in the last 6 months?
If yes, please explain:
Who is your Insurance Carrier?
What is your policy number?
What is your Provider's Service Number (1-800 number on the back of the card):
Is your Provider an: HMO or PPO
Consent to Treat
Please check all boxes below to agree to terms of service
Whether you are recovering from surgery, have a nagging injury, chronic pain, or just need preventative care, our Physical Therapists can help you. We want to get to know you and understand the activities that you love. We offer a continuum of care that is personalized for you.
The purpose of Physical Therapy is:
- To treat disease, injury and disability by evaluation, examination, testing and use of rehabilitative procedures, manipulations, massage, exercise and physical agents including, but not limited to, mechanical devices, heat, cold, electricity and ultrasound in the aid of diagnosis or treatment
- To obtain for the physician information needed in diagnosis and evaluations of patients
- To prevent or minimize residual physical injury or disability
- To aid the patient in achieving maximum potential within his or her capabilities
- To accelerate convalescence and reduce the length of the functional recovery
All procedures will be thoroughly explained to you before they will be performed.
There are certain inherent risks with Physical Therapy treatment because you will be asked to exert effort and perform activities with increasing degrees of difficulty. It is possible that this could cause an increase in your current level of pain or discomfort or an aggravation to your existing injury. There is also a possibility that you could experience a new injury. If any activity causes you to feel increased pain or discomfort, stop the activity and notify your therapist. This will help reduce the risk of injury or aggravation of your condition(s). The Physical Therapist will take care to ensure that you are protected from any hazardous situation. You will never be forced to perform any procedure that you do not wish to perform.
We at NAKOA Fitness and Physical Therapy keep a record of the health care services we provide you. We will not disclose your record to others unless you direct us to do so or unless a legal request authorizes or compels us to do so. We will provide copies of your records to your insurance company and referring physician as necessary to receive payment for our services. If you would like a copy of these records we would be happy to provide them to you.
Our Notice of Privacy Practices describes in more detail how your health information may be used and disclosed, and how you can access your information. This policy can be found on our website.
Based on the above information I agree to cooperate fully and to participate in all Physical Therapy procedures and to comply with the plan of care as it is established.
Check box to signify you have read and understand terms.
Rules, Regulations and Liability Waiver
1) RULES AND REGULATIONS. Client agrees to keep and obey all rules and regulations now in force or in the future prescribed by NaKOA or its associated exercise coaching centers, for the use of the exercise coaching and the equipment and facilities therein including rules with respect to lockers, uniforms, personal hygiene and safety. These rules are subject to change; changes will be posted. Client understands and agrees that NaKOA may revoke Client’s rights because of failure by the Client to obey the rules and regulations or because of any activity by the Client in using the facilities and services which create a nuisance, safety hazard, disturbs other members, or constitutes an act of moral turpitude or fraud. The rules and regulations are as follows;
A) Cancellation Policy - 24 hours notice is required for appointment cancellations. NaKOA LLC reserves the right to charge in full for all late cancellations. NaKOA reserves the right to cancel any future sessions as in its sole discretion it deems necessary. There is a $45 cancellation fee for all therapy appointments cancelled within 24 hours.
B) Refund Policy - NAKOA has a no Refund Policy
C) Dress Code - Shoes, shirts and appropriate exercise attire must be worn at all times.
D) Use of equipment - Place all weights gently on matted areas only after each set and place weights and all otherm accessories to the proper location after use.
E) Towel usage - All members must use a towel when using the equipment.
F) Guest Privileges - Guests must sign a liability waiver. All guests must be under the supervision of our staff. Client agrees to indemnify NaKOA , its affiliates, agents and employees against any and all liability incurred by them to any person brought into the facility as a guest.
G) Damaging property - Any Client who damages property of NaKOA will be charged for the replacement or repair of the damaged property.
H) Testimonials - NAKOA may want to share your successes on our social media platforms. By signing this agreement NAKOA has your permission to use your pictures (still or moving), voice recordings, statements and comments, in part or in whole, in any media, to promote their facility, products or services.
I) Heath Insurance Coverage - We will gladly call your insurance company to identify what your benefit coverage is,
however, please understand that insurance companies will not guarantee medical benefits prior to care. We can only use this information as an estimated guideline. Actual determination is made 4 to 8 weeks later after we receive the written notification and/or payments on your claim. We strongly encourage you to contact your insurance company directly in order to understand your plan’s coverage and limitations.
In the event that I, the patient, require more visits than my initially approved amount, NAKOA will request more visits from my insurance company as long as visits are medically necessary. I understand that visits that are pre-approved will not necessarily be reimbursed and that I am responsible for any remaining amount due.
Your insurance company may also require a current therapy prescription (prescriptions expire 30 days from the date they are written), a “Letter of Medical Necessity” written by your physician and/or pre-authorization directly from your physician for therapy services. This is your responsibility to obtain, and non-compliance with this may result in services not being reimbursed by your insurance company.
J) Payments - All deductibles, co-pays, and cash pay estimated amounts are due at the time of service. Once we received all payments or notifications from your insurance company, we will notify you immediately if we find that the benefits verified are inconsistent with payment received. Payment for any outstanding balance will be due upon immediate receipt of patient responsibility statement. If we do not receive the payment, we may be forced to pursue legal collection proceedings. Please do not hesitate to ask us any questions or request a copy of your account balance. Once again, we appreciate your choosing NAKOA Physical Therapy. Late Cancellation Policy: If you need to cancel your appointment, please do so more than 24 hours prior to the appointment time. If you cancel within 24 hours of the appointment time you will be charged a late cancellation fee of $45 dollars per visit.
By signing this form, I the patient (or legal guardian of the patient), have read, understood and agree that I am 100% responsible for all fees incurred here at NAKOA.
Physical Therapy that are not covered by my insurance company. I agree to authorize NAKOA Physical Therapy to release my medical information to insurance companies, physicians, attorneys and to all other pertinent parties that may be involved in my claim or care. I also agree to assign all payment of benefits to NAKOA Physical Therapy.
K) Aggregation of Data - (For Corporate use only) I agree to allow NAKOA, LLC share my aggregate data with my corporation (if applicable). I understand that only my aggregate data will be shared and not specifics about my health and/or progress. I understand that my anonymity will be upheld.
2) WAIVERS AND RELEASE. You (the Client) agree that you are aware you are engaging in physical exercise and the use of exercise equipment, center facilities, training and instruction, which could cause injury to you. You are voluntarily participating in these activities and assume all risks of injury to you that might result.
You hereby agree to waive any claims or rights you might otherwise have to sue NAKOA , its employees or agents for injury to you on account of these activities or your own negligence. You have carefully read this waiver and fully understand it is a release of liability. NAKOA will make an initial evaluation and recommendation whether Client or guests are sufficiently fit for any exercise activities. However It is always advisable to consult your physician before undertaking a physical exercise program.
Client warrants, represent and agree that he/she is in good physical condition and that he/she has no disability impairment or ailment preventing he/she from engaging in active or passive exercise or that will be detrimental or inimical to their own health, safety, comfort, or physical condition or that of others if he/she does so engage or participate. Client represents that he/she will not use the facility with any open cuts, abrasions, infections, maladies with the potential of harm to others, or otherwise in accordance with public health requirements. The management of each club shall have the final determination in this regard.
3) MISCELLANEOUS. Management reserves the right to alter or amend these rules or change the fees at any time. Management also reserves the right to alter or adjust the equipment in its facilities at any time. Classes, equipment and training sessions are available subject to demand and may be crowded at peak hours, or may be discontinued or times changed if demand fluctuates.
4) LOST AND FOUND. NAKOA will not be held responsible for lost or stolen articles. We highly recommend that you leave all valuables at home when coming to the center. The center maintains a lost and found area; however, we cannot guarantee the security of these items. Items left over 30 days are given to charity.
5) ENTIRETY OF AGREEMENT. This Rules, Regulations & Liability Waiver and the Client Agreement constitute the entire exclusive agreement between the parties. Any promises, representations, understandings and/or agreements pertaining directly or indirectly to this Rules, Regulations & Liability Waiver and the Client Agreement, which are not contained herein, are hereby waived. Only an instrument in writing may modify these Rules, Regulations & Liability Waiver and the Client Agreement; however, Seller or assignee of these Rules, Regulations & Liability Waiver and the Client Agreement is hereby authorized to correct patent errors in the Rules, Regulations & Liability Waiver and the Client Agreement (and in other documents, if any, executed in connection herewith). At Seller's option, these Rules, Regulations & Liability Waiver and the Client Agreement shall be null and void if Seller’s employee in accordance with Seller’s then-¬?current price and payment programs does not complete it. No change to any printed term in our Rules, Regulations & Liability Waiver and the Client Agreement shall be valid. If any particular provision of this Rules, Regulations & Liability Waiver and the Client Agreement is invalid, the same shall not affect the other provisions hereof.
WELCOME TO NAKOA ! Our pledge to you is to operate our business according to the following “Values and Mission”. These are the expectations that govern our staff and our business and represent our commitment to you, the member, by checking the box below this waiver you agree to follow these as well.
I accept all terms.