wellbody Club/Team Name:____________________
Focused on the healthcare of athletes. Level/Age Group: ____________________
I, ____________________, allow my child, _________________________, to participate in a preventative injury
Parent/Guardian Name Athlete/Child Name
program initiated by __________________________. Board Certified in Pediatrics with a special interest in
Club/Team Name
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 waived with this form) 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 _____________________. Dr. Goldstein is not paid and he does not
Club/Team Name
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. 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
five USA Gymnastics Schools, a swimming club, a baseball club, and three soccer clubs.
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, a massage therapist, 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 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 coaching staff. Confidentiality of the visit is waived by the opportunity to have medical advice during practice. 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.