Treatment Consent

Please review and sign this Treatment Consent & Release form before undergoing any treatment, including an injury screens or PT recovery session.

Name

First Name

Last Name

Phone

(###)

###

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Consent Form

I hereby give consent to CoreMovement Physical Therapy LLC to provide medical care and treatment as requested by myself, or my family member(s). I understand today’s services are not part of an established plan of care. They are not intended to fully treat or cure my condition, but rather serve as an assessment and/or recovery adjunct. While CoreMovement Physical Therapy LLC fully intends to provide services that offer no harm, I understand there are inherent risks in receiving medical treatment and recovery adjuncts. I do not hold CoreMovement Physical Therapy LLC liable for any injury sustained. I understand that CoreMovement Physical Therapy LLC is a hands-on Physical Therapy clinic. Though highly specialized, treatment consists primarily of manual therapy techniques and treatment forms that are published or otherwise publicly known. Forms of electrical stimulation, deep tissue massage, therapeutic exercise programs, neuromuscular re-education, dry needling, myofascial release, joint and soft tissue manipulation, as well as other treatment modalities may be used. Some of the hands-on treatment techniques require deep pressure or the use of needles which may cause bruising and periods of increased soreness which may last from 6-72 hours. I understand that photographs and video may be taken for educational purposes. By signing below, I consent to the use of these photographs and videos in a private and professional manner.

I have read & fully understand the waiver form*

Yes

By checking this box and typing my name above, I am electronically signing this Liability Waiver form. My signature indicates that I agree with and understand everything discussed in this waiver form.

I agree