How did you hear about our facility? _________________________________________________
(please check one)
□ New Member
□ Current Member
□ Former Member or Cardiac Rehab Graduate
For Office Use Only: Healthways Members
□ SilverSneakers
□ Prime
16 digit ID# ______________________________
Full Name: _____________________________________________________________________
Last First M.I.
Address: _____________________________________________________________________
Street Address Apartment/Unit#
_____________________________________________________________________
City State Zip Code
Home Phone: _(_____)__________________ Cell Phone: _(_____)__________________
Employer: ____________________________ Work Phone: _(_____)__________________
Birth Date: _________________ Gender: M F
Full Name: _______________________________________________________________________
Last First M.I.
Home Phone: _(_____)__________________ Cell Phone: _(_____)___________________
Relationship to Member: _________________ Work Phone: _(_____)___________________
Primary Care: __________________________ Cardiologist: __________________________
Other(s): ________________________________________________________________________
(please check one)
□ Basic
Type Benefits
Basic membership – Self-managed
□ Enhanced
Basic membership, plus exercise prescription, blood pressure checks, more
□ Medically-Supervised
Enhanced, plus clinical medical supervision
Cost per Month
Standard members - $30
Healthways members - free
Standard members - $40
Healthways members - $10
Standard members - $45
Healthways members - $15

(please check one)
□
Monthly Statement
• Basic – Statements are mailed between the 1 st and 10 th of each month.
• Enhanced and Medically-Supervised – Statements are attached to your exercise prescription
between the 1 st and 10 th of each month.
□
Electronic Funds Transfer
• You may have your dues automatically transferred from a savings or checking account or from a
credit or debit card. For this payment option , you must fill out and attach an Authorization for
Electronic Funds Transfer Form, which is available in the front office.
• Lockers are free to all New Heart members for day use. Members are asked to bring their own locks and take
their belonging with them when they leave.
• Rental of lockers for overnight use is available upon request for a fee of $10 per month.
• Locks left on day-use lockers overnight, or on rented lockers past the rental period, will be cut off. Any belongings in such lockers will be stored in our lost and found for one month and then discarded if not claimed .
Billing
• You are responsible for paying your monthly fee, regardless of your attendance, until you cancel
your membership by contacting a member of the front office staff.
• The billing cycle is from the first day of the month to the last day of the month.
• Payments are due by the 20 th of each month.
• We only pro-rate monthly membership dues when a member initially signs up and when a
membership is reopened after being canceled for an entire calendar month or more.
• Membership dues are not refundable .
Account Termination or Reactivation
• Your membership will remain active, regardless of attendance, until canceled by contacting a front
office staff member.
• If you will be gone for an entire calendar month or more, please notify a front office staff member in
advance so we may cancel your membership and prevent the billing system from charging you.
• Your membership may be reactivated at any time. If it has been 6 months or more since you were in
last, you will be required to fill out new membership forms and get physician clearance when indicated.
I fully understand and acknowledge that fitness activities and usage of fitness equipment have (a) inherent risks, dangers, and hazards;
(b) my participation in such activities and/or use of such equipment may result in injury or illness including, but not limited to, bodily injury, disease, strains, fractures, partial and/or total paralysis, ailments that could cause serious disability or death; (c) my participation in these activities is commenced after taking the New Heart Physical Activity Readiness Questionnaire normally given to members of New Heart and I have taken responsibility for obtaining medical clearance (if required) prior to beginning my exercise program; (d) by my participation in these activities and for use of equipment, I hereby assume all risks and dangers and all responsibility for any losses and/or damages.
I, on behalf of myself, my personal representatives, and my heirs, hereby voluntarily agree to release, waive, discharge, hold harmless, defend, and indemnify New Heart and its representatives, employees, and volunteers from any and all claims, actions, or losses for bodily injury, property damage, wrongful death, loss of services or otherwise which may arise out of my use of any equipment or participation in these activities. I specifically understand that I am releasing, discharging, and waiving any claims or actions that I may have presently or in the future.
I HAVE READ THE ABOVE WAIVER AND RELEASE AND BY SIGNING IT AGREE. IT IS MY INTENTION TO EXEMPT
AND RELIEVE NEW HEART FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH
CAUSED BY NEGLIGENCE OR ANY OTHER CAUSE.
Member’s Signature _______________________________________________
Date _________________
Parent or Guardian’s
Signature (if under 18) _____________________________________________ Date _________________
Revised 9/13/15-ss

We have your health in mind. Please take a few moments to fill out this short questionnaire to aid our determination of your readiness to begin exercising. Depending on the results you may be required to complete a Cardiac Risk
Assessment or obtain clearance from your Physician prior to starting to exercise.
Section 1: Member Information
Name_____________________________________ Date of birth___________ Today’s date___________
1. Yes No Has your doctor ever told you that you have heart trouble?
If yes, please describe: ___________________________________________________
2. Yes No Have you ever had a heart attack or been hospitalized for a heart related matter?
3. Yes No Do you ever experience chest pain or abnormal shortness of breath when exercising?
4. Yes No Do you have diabetes?
5. Yes No Are you under the care of a physician(s) for any medical condition?
If yes, please describe: ___________________________________________________
6. Yes No Do you ever feel faint or have dizzy spells?
7. Yes No Do you have any bone, joint or back conditions that could be made worse by exercise?
If yes, please describe: ____________________________________________________
8. Yes No Do you lose your balance, trip or fall when walking or exercising?
9. Yes No Is there any reason why you should not begin an exercise program at this time?
If yes, please describe: ___________________________________________________
10. Yes No Are you currently under the care of a physician for high blood pressure?
11. Yes No Do you smoke?
12. Yes No Does your physician have concerns about health risks related to your weight?
If yes, please explain:_____________________________________________________
Section 2: NH Staff - circle the appropriate number below and check any corresponding boxes for that number, initial next to the number
1. If “ Yes ” to any of questions 1-3, must complete a Cardiac Risk Assessment (CRA) or obtain medical clearance from their PCP or cardiologist.

Cardiac Risk Assessment

Obtain medical clearance
2. If “Yes” to question 4, must obtain medical clearance from their PCP or physician treating diabetes.
 Clearance required
3. If “ Yes ” to any of questions 5-10, may require medical clearance prior to starting our exercise program.
 Clearance required  No clearance required
4. If “ No ” to all the above questions, may begin exercising in the desired exercise program.
Section 3: Physician Release
is cleared to exercise in the New Heart Exercise and Wellness Program.
(Patient Name)
Physician Signature________________________________________________________ Date__________
Physician Name (please print)________________________________________________
Physician Address____________________________________________________Phone #____________________

Date: _____/_____/_____
Name: _______________________________________________________ DOB: _____/_____/_____
Are you allergic to any medications?  No  Yes
If yes, please list
Please list the medications you are currently taking.
.
MEDICATION NAME DOSE FREQUENCY
(e.g. 500mg) (e.g. 1 tablet 2x/day or 1 drop 2x/day)
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Revised 6/10/14-ss