wellbody Site Visit Consent 2010 Club/Team Name:____________________
Focused on the healthcare of athletes. Level or Age Group: __________________
I, ________________________, allow my child, _______________________, to participate in a preventative injury
Parent/Guardian Name Athlete/Child Name
program initiated by ______________________ (below will be designated as *Team).
Club/Team/Facility Name
Board Certified in Pediatrics with a special interest in Sports Medicine, Dr. Randy Goldstein will make scheduled visits to the *Team to
assist athletes with injury care, injury prevention, and general health care recommendations.
By signing this form, I permit my child to be evaluated by Dr. Goldstein during a site visit to the *Team in the presence of a coach.
a) I realize that should my child discuss an issue with Dr. Goldstein- this consult will ALWAYS be discussed with a member of the
coaching staff. A parent/guardian may or may not be present during the evaluation- but a member of the coaching staff will be present
as the permitted guardian in the absence of a parent.
b) I understand that HIPAA regulations are waived with this form and communication with the coach with or without the parent
present is permitted.
c) There will be NO FINANCIAL charge to my family, the booster club, the coaching staff, or the *Team for this service.
Facility Statement: The coach(es) and owner(s) of the *Team permit Dr. Goldstein to evaluate and consult with athletes on site. Dr. Goldstein is NOT an
employee, paid consultant, or agent of the *Team. Dr. Goldstein is not paid nor does he pay any coach or owner to participate in this service. There is
no contract between the *Team and Dr. Goldstein, no guarantee of a scheduled site visit and no guarantee of follow up assessments or
recommendations after an initial consultation with my child. Either party (the *Team or Dr. Randy Goldstein) may request to cancel site visits at any
time and for any reason. The ownership of the *Team does not represent an opinion concerning Dr. Goldstein’s advice, expertise, diagnosis, or
recommendations except to recognize that he is Board Certified in Pediatrics with an interest in Sports Medicine.
This consent is valid for one year from the date signed. If I wish to no longer have my child participate in the wellbody site visit program, I can mail a
signed, dated request at any time to: wellbody, 6376 College Blvd, Leawood, Kansas 66211.
Signature ______________________________ Date: ____________ Phone Number ___________________________
Email: ___________________________________
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Mission Statement of the wellbody Program____________________________
Who is Dr. Goldstein: Dr. Randy Goldstein is a board certified Pediatrician with an interest in 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 for preventative injury and
health care information.
What is wellbody? wellbody was created from the “college” type medical/injury prevention program and redesigned to fit into youth (age group) sport's
clubs- where the medical professional regularly visits the athletic facility. This type of program attempts to protect the athletes from future injury and
helps return injured athletes to the sport more quickly. Often athletes and parents delay going to the doctor due to copays, the fear of sports unfriendly
treatment plans, coaches and athlete's apprehension of what the doctor may recommend, and unpleasant past experiences in a doctor's office.
wellbody site visits are free: There is no fee to the family or the facility during a site visit. Dr. Goldstein is passionate about offering sport's friendly
care to young athletes. Site visits to facilities are considered a free community service.
How wellbody works: Unlike a consultation in a private office of a family doctor or pediatrician, these consultations are at the sport’s 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 the coaching staff.
Confidentiality of the visit is waived by the opportunity and convenience of having on site sports friendly medical advice. 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, or a medication need to be prescribed, in your opinion, an appointment in the private office setting of either Dr.
Goldstein or your personal physician should be scheduled .
Dr. Goldstein will become familiar with the workouts, expectations of coaches and athletes, and enable athletes to continue with these expectations (at
times with recommendations or certain restrictions). Physicians in private offices unfamiliar with the dynamics of the team or the competition schedule
may recommend complete activity restriction, and in some cases this may be unnecessary. Modified activity might be a better alternative.
Questions may be asked about sports involvement with headaches, stomach aches, asthma, allergies, as well as injury and injury prevention. This
program also allows quick access to sports friendly consultants with the same attitude as Dr. Goldstein. Consultants include dieticians, orthopedics,
psychologists, a massage therapist, physical therapists, and an endocrinologist (growth expert)- all with the understanding that the patient is an athlete.
Site visits are not intended to replace your general physician's health care or well child visits- although many athletes choose to get their general health
care at Dr. Goldstein’s office once a relationship is made at the athletic facility. The consultation during a site visit is purposely in front of parents,
other athletes, and staff. It is therefore not an exhaustive evaluation but rather a screening tool to advise if further diagnostic work up or treatment is
recommended.
The wellbody goal: As a team physician, Dr. Goldstein is interested in keeping athletes happy and healthy in the setting of their 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.
www.wellbodykc.com