INFORMED CONSENT & RELEASE OF LIABILITY

I am voluntarily participating in physical therapy and/or wellness services provided by Even Keel Wellness and Physical Therapy. I will be receiving instruction and information concerning fall prevention, which may include physical activity and/or home assessment and modifications recommendation. I represent and warrant that I have no physical or mental health condition that would prevent my safe participation. I agree that if I have any known medical history that may result in an adverse reaction in connection with physical activities, I will consult with and obtain the permission of a physician prior to engaging in any physical activities.

I am willingly and voluntarily assuming any risks, injuries, or damages, known and unknown, which I might incur as a result of participating in physical therapy and/or wellness services, and agree that Even Keel Wellness and Physical Therapy will not have any liability for such injuries or damages, to the maximum extent allowed by applicable law.

I acknowledge and agree that Even Keel Wellness and Physical Therapy is not a medical doctor and does not provide any medical diagnoses or treatments. I agree that if I have any medical condition, I will seek the help of a medical doctor.

To the maximum extent permitted by applicable law, I hereby (a) waive and release any claims, known or unknown, I may have against Even Keel Wellness and Physical Therapy, including its instructors, officers, directors and employees and agents, arising from or in connection with the services provided by Even Keel Wellness and Physical Therapy (“Claims”) and agree to indemnify Even Keel Wellness and Physical Therapy, including its instructors, officers, directors and employees and agents, from and against any and all Claims.

As with all forms of physical therapy and wellness services, there are benefits and risks. Since the physical response to a specific treatment can vary widely from person to person, it is not always possible to accurately predict the patient’s response to a certain modality or activity. It is impossible to predict an individual patient’s reaction to a particular treatment might be, nor can it be guaranteed that the treatment will help the condition the patient is seeking treatment. There is also a risk that the treatment may cause pain or injury or may aggravate previous existing conditions.

The patient has the right to ask the physical therapist what type of treatment is planned based on medical history, diagnosis, symptoms and testing results. The patient may ask the therapist about the potential risks and benefits of a specific treatment. The patient has the right to decline any portion of the treatment at any time before or during the treatment session.

Therapeutic exercises are an integral part of most physical therapy and wellness treatment plans. Exercise has inherent physical risks associated with it. If the patient has any questions regarding the type of exercise that he/she is performing and any specific risks associated with these exercises, the therapist will be glad to answer them.

I understand the risks associated with a program of physical therapy and wellness as outlined to me and wish to proceed.
I understand and agreeI do not understand and agree

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