Proven PT and Wellness, PLLC

 

 

PHYSICAL THERAPY TERMS AND CONDITIONS RELEASE OF LIABILITY

 

              I fully understand that the physical therapy programs and/or water exercise programs offered by Proven PT and Wellness, PLLC require physical activity, and I hereby represent and acknowledge that my physical condition permits me to participate. I acknowledge that I have been advised that at any time I am having physical difficulty of any kind to notify the physical therapy personnel and carefully stop all activity. I acknowledge and accept the responsibility and all of the risks.

 

Proven PT and Wellness, PLLC is not responsible for loss of or damage to any personal effects (money, jewelry, etc.). I agree to abide by the facility rules and guidelines. I agree to conduct myself in a safe manner at all times.

 

I also release and discharge on behalf of myself, my heirs, assigns and successors in interest, all officers, directors, owners, agents and employees, any venues, facilities and other representatives of Proven PT and Wellness, PLLC, and its insurers, from any and all claims, damages, demands, losses, and liabilities arising out of or in any way related to participation in any Proven PT and Wellness, PLLC's physical therapy programs, exercise programs, class activities, procedures, swim or any other activities or results attained therefrom. The patient is informed that Proven PT and Wellness, PLLC's telehealth sessions may be subject to audio and visual surveillance.

 

 

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Patient Name (print)

 

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Patient Signature                                                                                                            Date

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