Clinical Services Event - Athletico

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Find an Athletico.

Address, City, State, or Zip code

Find A Location

For internal employee use only. This form is to be submitted at least 60 days prior to event.

Please use the drop down below to choose the screening opportunity you are submitting. Upon completing the form, it will be routed to the respective Program Manager for review and approval. Response may take up to 5 business days. If this is an urgent request, please reach out to the Program Manager to expedite the process after completing your form submission.

Program*
Your Email:*
Organization Information
Name of Organization*
Description of Organization*
Organization's Website*
Do we have an established contract/agreement with the organization?
- Yes
- No
- I don't know
Do you know who from the organization will be signing the contract?*
- Yes
- No
Name
First Last
Title
Email
Is there a local clinic that this organization supports? If Yes, please indicate which clinic(s) and their address.*
- Yes
- No
What is the local clinic that this organization supports*
Please select requested services for this organization (check all that apply):
- Gym/Cheer Biomechanical Screens
- Warm-Up Instruction
- Gym/Cheer-specific conditioning programs
- On-site competition or practice coverage
Please select requested services for this organization (check all that apply):
- Injury Prevention Workshops
- Developing appropriate training progressions
- Cross country/track team screens
Please select requested services for this organization (check all that apply):
- Planning services – Concussion Protocol
- ImPACT Testing (baseline and post-concussive)
- SCAT5 Testing
- Return to Participation + Return to Learn Consultation
Please select requested services for this organization (check all that apply):
- Risk Assessment Screens
- Sport-Specific Dynamic Warm-Up Instruction
- Movement Workshop
Please select requested services for this organization (check all that apply):
- Functional Movement Screens
Please select requested services for this organization (check all that apply):
- Overhead Athlete Biomechanical Screen
- Video Throwing Analysis
- Fault Correction Strategies/Drills
- Swim Screen
Please select requested services for this organization (check all that apply):
- Pointe Readiness Screens
Please select requested services for this organization (check all that apply):
- Relative Energy Deficiency in Sports (RED-S) written screens
- Pelvic Health written screens
- Lectures on RED-S and pelvic health
Please select requested services for this organization (check all that apply):
- Lectures on opioid addiction
Screening Event Information
Target date of event*
MM slash DD slash YYYY
Requested decision by date*
MM slash DD slash YYYY
Start Time*

: Hours

Minutes

AM/PM
Duration of screening event*
Location of screening event*
Street Address Address Line 2 City State ZIP Code
Number of event participants*
Will GAP be requested for this event?*
- Yes
- No
GAP costs will show up in section A below. If GAP is not being requested, section A will not show in total costs.
If GAP requested, has your RD and AT Manager approved this event for GAP time?
- Yes
- No
If GAP approved, Cost Center:
Number of PTs requested:*
Number of PTAs requested:*
Number of ATCs requested:*
# of Staff (total from above)
# of Staff (no GAP, total from above)
staff
staff (no GAP)
A. Approximate Staffing Cost
$0.00
B. Sponsorship Cost (if none, please indicate "0"):*
A. Sponsorship Cost (if none, please indicate "0"):*
C. Premium Items and Collateral Cost (if none, please indicate "0"):*
B. Premium Items and Collateral Cost (if none, please indicate "0"):*
To find these costs please visit the marketing ordering system, login, and select the materials you will use at the event. Unsure of what to bring? Please reference the document “How to use Athletico Branded Marketing Materials” located on sharepoint, here.
Cost to be Onsite and Offer Screens (Total from A,B,C above) (if none, please indicate "0"):
Cost to be Onsite and Offer Screens (Total from A & B above) (if none, please indicate "0"):
Deliverables for this event (select all that apply)*
- ACL Risk Assessment Report Card to athlete
- Summary of findings to coach for all athletes
- Post-screen meeting with athlete in clinic
- Instruction in sport-specific dynamic warm-up program with handouts
- Tiered HEP
- Weekly supervised progressive prevention program
- Lecture
- Other (please specify):
Deliverables for this event (select all that apply)*
- Corrective exercises
- Summary of finding to coach for all athletes
- Post-screen meeting with athlete
- Fault correction strategies/drills
- HEP
- Lecture
- Other (please specify):
Deliverables for this event (select all that apply)*
- HEP
- ACL Risk Assessment Report Card to athlete
- Summary of findings to coach for all athletes
- Cheerleading or gymnastics dynamic warm-up
- Cheerleading or gymnastics conditioning program
- Instruction in sport-specific dynamic warm-up program with handouts
- Post-screen meeting with athlete in clinic
- Lecture
- Other (please specify):
Deliverables for this event (select all that apply)*
- VGA Report Card to Runner
- VGA Booklet
- Bike Fit Report Card to Cyclist
- Summary of Findings to Coach or Physician
- Post-screen phone call or meeting with client
- Summary of finding to coach for all athletes
- Post-screen meeting with athlete
- Fault correction strategies/drills
- HEP
- Lecture
- Other (please specify):
Deliverables for this event (select all that apply)*
- Corrective balance exercises
- Summary of findings to parent for athlete
- HEP
- Lecture
- Other (please specify):
Deliverables for this event (select all that apply)
- VTA report card
- Summary of findings to coach or physician
- Summary of findings to coach for all athletes
- Post-screen phone call or meeting with clients
- Fault correction strategies/drills
- HEP
- Lecture
- Other (please specify):
Other:
Is there a physician connection with this group? If Yes, please indicate the physician and physician group name.*
- Yes
- No
Please fill in physician and physician group name*
Physician Name Physician Group Name
What is the estimated number of potential new patients that this opportunity could generate?
Please upload any supporting documents that you feel would be helpful in evaluating this partnership.
Drop files here or

Max. file size: 20 MB.
Name
This field is for validation purposes and should be left unchanged.

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Athletico Physical Therapy cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, edad, religión, sexo, origen nacional, condición socioeconómica, orientación sexual, identidad o expresión de género, discapacidad, condición de veterano o fuente de pago. Serás tratado con dignidad, compasión y respeto como individuo.

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