wellbody                GYMNASTICS Focused on the healthcare of athletes.                                        I, ____________________, allow my child, _________________________, to participate in a preventative injury program initiated by the gym. Board Certified in Pediatrics with a special interest in Sports Medicine, Dr. Randy Goldstein will make scheduled visits to assist athletes with injury care, injury prevention, and general healthcare. I realize that should my child discuss an issue with Dr. Goldstein during his visit to the facility- this consult will ALWAYS be discussed with a member of the coaching staff as well as the parent/guardian. By signing this form, I agree to have my child evaluated by Dr. Randy Goldstein in the presence of the coach. A parent/guardian may or may not be present during the evaluation- but a member of the coaching staff will be present in the absence of the parent. (HIPPA regulations are voluntarily waived with this form- as permission is given to discuss athlete health-care with coach) There will be NO FINANCIAL charge to my family, the booster club, the coaching staff, or the owner of the facility for this service. Statement: The coaches permit Dr. Randy Goldstein to evaluate and consult with athletes. Dr. Goldstein is NOT an employee, paid consultant, or agent of Diamond Gymnastic and Dance Center. Dr. Goldstein is not paid and he does not pay any coach or owner to participate in this service. Additionally, no funds (including booster club or team funds) will be used for payment to Dr. Goldstein for these site visits. The ownership does not represent an opinion concerning Dr. Goldstein’s advice, expertise, diagnosis, or treatment except to recognize that he is Board Certified in Pediatrics with an interest in Sports Medicine. Signature ___________________________________   Date: __________  Phone Number _____________________ Mission Statement of wellbody Program Dr. Randy Goldstein is a board certified Pediatrician with an interest in Sports Medicine. He is a fellow of the American Academy of Pediatrics. He has been a resident member of the American Medical Society for Sports Medicine as well as a member of the American College of Sports Medicine. As a retired competitive gymnast and gymnastics coach, he is motivated to continue his participation with sport. Several premier level programs use his services including four USA Gymnastics Schools, a premier level swim program, and St. Mary’s University (an NAIA college). This “college” type medical/injury prevention program- where the medical professional regularly visits the athletic facility- rather than the athlete visiting the doctor- protects the athletes from future injury and has proven to return injured athletes to the sport more quickly. Often athletes and parents wait to go to the doctor. Copays, sports unfriendly treatment plans, and unpleasant experiences cause athletes to delay physician input. With wellbody, there is no fee to the family or the team during facility visits. Questions may be asked about sports involvement with headaches, stomach aches, asthma, allergies, as well as injury and injury prevention. This program allows quick access to sports friendly consultants with the same attitude as Dr. Goldstein. Consultants include dieticians, orthopedics, psychologists, and physical therapists- all with the patient considered an athlete. Site visits are not intended to replace your general physicians health care or well child visits- although many athletes choose to get their general healthcare at Dr. Goldstein’s office once a relationship is made at the athletic facility. The consultation is purposely in front of parents and/or staff. It is therefore not an exhaustive evaluation but rather a screening tool to advise if further treatment is necessary. Unlike a consultation in a private office of a family doctor or pediatrician, these consultations are at the athletic facility during a scheduled practice. A concerned athlete will obtain permission from the coach to ask questions to Dr. Goldstein. All visits will be followed with contact to a parent/guardian by written form or telephone call. Also, unlike a visit to a private office, this visit will be discussed with coaching staff. Confidentiality of the visit is waived by the opportunity to have medical advice at the athletic facility. Dr. Goldstein will become familiar with the workouts, expectations of coaches and athletes, and enable athletes to continue with expectations (at times with certain restrictions). Typically, physicians in private offices may not understand the dynamics of the team or the meet schedule and completely restrict activity unnecessarily. In the interest of the athlete/physician/coach relationship it is imperative that each party be involved with the recommendations offered during these consultations. Should a confidential visit be necessary, an appointment in the private office setting of either Dr. Goldstein or your personal physician should be scheduled. As a team physician, Dr. Goldstein is interested in keeping athletes happy and healthy in the setting of the sport. This goal is aggressive towards sports participation while still following the recommendation of the American Academy of Pediatrics. Please discuss any questions with the head coach of your program or phoning Dr. Goldstein at 913-469-1225.