Consent to Treat/Release of Liability
As a client of drive PT LLC, you will be evaluated and treated based on your presenting
signs and symptoms and past medical history. The purpose of physical therapy is to
treat disease, injury, and disability through examination, evaluation, diagnosis, and
prognosis. In order to improve your current function and disability, interventions such as
mobilization, massage, manipulation, exercise, dry needling, and/or use of modalities
may be used in your treatment. Response to physical therapy treatment varies from
person to person, and while the likelihood of adverse events is low, there are risks of
soreness, aggravation of existing condition, skin irritation and cardiovascular
complications such as rapid heart rate, shortness of breath, cardiac arrest, and/or
cerebral vascular accident. It is your right to decline any part of your treatment at any
time before or during treatment. It is also your right to discuss the potential risks and
benefits involved in your treatment.
I have read this consent form and understand the risks involved in physical
therapy. I consent to physical therapy evaluation and treatment by drivePT LLC,
and I agree to comply with the established plan of care. I understand that I have
the right to ask about these risks and ask any questions about my conditions
prior to treatment. I know it is up to me to inform the physical therapist/staff
about any health problems or allergies I have, as well as medications I am taking.
I specifically understand that I am releasing, discharging, and waiving any claims
or actions that I may have presently or in the future for the negligent acts or other
conduct by the representatives or employees of drivePT LLC. I acknowledge the
risk associated with using CrossFit Bear’s equipment, and I agree to not hold
CrossFit Bear or its employees or representatives liable. I will not hold drivePT
LLC or CrossFit Bear liable for any adverse effects or injuries that occur on the
I acknowledge that I have received a copy of drivePT’s Consent to Treat/Release of Liability
I acknowledge that I have received a copy of drivePT’s Consent to Treat/Release of Liability and agree to it.
Send me a copy of my responses.
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