Warrior Health and Fitness

REGISTRATION FORM

To be connected to a member of our team, please complete and submit a registration form:

Name*

First Last

Date of Birth*

Gender

Male

Female

Non-binary

Prefer not to respond

Street

Address

City State

Zip Code

Email*

Preferred Phone*

I am a*

Service Member or Veteran

Family member of a Service Member or Veteran

Both

The Partners HealthCare standard is to send email securely. This requires you to initially set up and activate an account with a password. You can then use the password to access secure emails sent to you from Partners HealthCare. If you prefer, we can send you "unencrypted" email that is not secure and could result in the unauthorized use or disclosure of your information. If you want to receive communications by unencrypted email despite these risks, Partners HealthCare will not be held responsible. Your preference to receive unencrypted email will apply to:

For research: Emails sent to you from research staff in this study. If you wish to communicate with other research staff at Partners regarding additional studies, your preference will have to be documented with each research group.

For clinicians: Emails sent from clinicians and staff at this practice or department.

Permission to email unencrypted messages?*

Yes

How did you hear about us?

Home Base

Florida Warrior Health and Fitness

REGISTRATION FORM