New Member Registration & Liability Release Agreement
Mini's House of Pain and Mikla Dunning Physical Therapy Systems
Name *
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Gender *
Member Date of Birth *
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Mailing Address (Street) *
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City *
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State *
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Zip Code *
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Best Contact Number (no dash or space) *
9165555555
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Parent/Guardian Mobile Number
If under 18
Email *
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Emergency Contact Name *
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Emergency Contact Number *
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Emergency Contact Relationship *
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Referred By: *
Name of who referred you
Thank You!
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Name of who referred you
Thank You!
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Agreement Purpose
Purpose of This Binding Agreement: By reading and signing this document, "You," the undersigned, sometimes also referred to as "User" or "I," will agree to release and hold Mini’s House of Pain Inc., and their respective agents, assignees, heirs and affiliates ("Releasee" or "We") harmless from, and assume all responsibility for, all claims, demands, injuries, damages, actions or causes of action to persons or property, arising out of or connected with your use of the Gym, premises, or services offered at 4990 Hillsdale Circle Ste. 100, El Dorado Hills, CA 95762, or other such locations as used by the company including off-site training locations utilized on an ad hoc basis. The agreement and release is for the benefit of the Gym, its employees, agents, independent contractors, other users of the Gym and all persons on the Gym’s premises. This agreement includes your release and indemnification of these persons from responsibility for injury, damage, or death to yourself because of those acts or omissions claimed to be related to the ordinary negligence of these persons. This agreement also includes your representations as to important matters that the Release will rely upon.
A: *
Waiver and Release of Liability: Representations: A. The undersigned, “You,” represent: (a) that you understand that use of the Gym, equipment, services and programs includes an inherent risk of injury to persons and property; (b) that you are in good physical condition and have no disabilities, illnesses, or other conditions that could prevent you from exercising and using the Gym’s equipment without injuring yourself or others, or impairing your health; and (c) that you have consulted a physician concerning an exercise program that will not risk injury to yourself or impairment of your health. Such risk of injury includes, but is not limited to, injuries arising from or relating to use by you or others of exercise equipment and machines, locker rooms, shower and other wet areas, and other Gym facilities; injuries arising from or relating to participation by you or others in supervised or unsupervised activities or programs through the Gym; injuries and medical disorders arising from or relating to use of the Gym including heart attacks, sudden cardiac arrests, strokes, heat stress, sprains, strains, broken bones, and torn muscles, tendons, and ligaments, among others; and accidental injuries occurring anywhere in or around the Gym including lobbies, hallways, exercise areas, bathrooms, outside walkways and parking areas. Accidental injuries include those caused by you, those caused by other persons, and those of a "slip-and-fall" nature. If you have any special exercise requirements or limitations, you agree to disclose them to the Releasee before using the Gym; and when seeking help in establishing an exercise program, you hereby agree that all exercise and use of the Gym facilities, services, programs, and premises are undertaken by you at your sole risk. You do hereby further declare yourself to be physically sound and suffering from no condition, impairment, disease, infirmity, or other illness that would prevent your participation or use of equipment or machinery except as hereinafter stated. You do hereby acknowledge that you have been informed of the need for a physician's approval for your participation in an exercise/fitness activity or in the use of exercise equipment and machinery. You also acknowledge that it has been recommended that you have a yearly or more frequent physical examination and consultation with your physician as to physical activity, exercise, and use of exercise and training equipment so that you might have his recommendations concerning these fitness activities and equipment use. You acknowledge either that you have had a physical examination and have been given your physician's permission to participate, or that you have decided to participate in activity and use of equipment and machinery without the approval of your physician and do hereby assume all responsibility for your participation and activities, and utilization of equipment and machinery in your activities. You are not permitted to use the Gym during non-supervised hours. You realize that if you use the Gym during non-supervised hours, any emergency response to you in the event of need for same may be impossible or delayed. You realize that a delay in the provision of first aid and/or emergency response may result in greater injury and disability to you and may cause or contribute to your death.
B: *
Waiver and Release of Liability: Express Assumption of All Risks: B. You have represented to us and acknowledged that you understand and appreciate all of the risks associated with your participation in various activities at the Gym and in the use of equipment, including the risks of injury, disability, and death. Knowing and appreciating all of these risks and enhanced risks, you have knowingly and intelligently determined to expressly assume all risks associated with all of your activities and use of equipment at the Gym. You understand and are aware that strength, flexibility and aerobic exercise, including the use of equipment, is a potentially hazardous activity. You also understand that fitness activities involve the risk of injury and even death, and that you are voluntarily participating in these activities and using equipment and machinery with knowledge of the dangers involved. We have also reviewed the risks with you on the date when you signed this Agreement and answered any questions that you may have had. You hereby agree to expressly assume and accept any and all risks of injury or death including those related to your use of or presence at the Gym, your use of equipment, and your participation in activity, including those risks related to the ordinary negligence of those released by this Agreement and including all claims related to ordinary negligence in the selection, purchase, setup, maintenance, instruction as to use, and use and/or supervision of use, if any, associated with all equipment and facilities. C. Agreement and Release of Liability In consideration of being allowed to participate in the activities and programs of the Gym and to use its equipment and machinery in addition to the payment of any fee or charge, you do hereby waive, release, and forever discharge the Releasee and their directors, officers, agents, employees, representatives, successors and assigns, administrators, executors, and all others from any and all responsibilities or liability from injuries or damages resulting from your participation in any activities or your use of equipment/facilities or machinery in the abovementioned activities. You do also hereby release all of those mentioned and any others acting upon their behalf from any responsibility or liability for any injury or damage to yourself, including those caused by the negligent act or omission of any of those mentioned or others acting on their behalf or in any way arising out of or connected with your participation in any activities of the Gym. This provision shall apply to ordinary acts of negligence but shall not apply to gross acts/omissions of negligence, willful or wanton acts/omissions, or those of an intentional/criminal nature.
C: *
Waiver and Release of Liability: Agreement and Release of Liability: C. In consideration of being allowed to participate in the activities and programs of the Gym and to use its equipment and machinery in addition to the payment of any fee or charge, you do hereby waive, release, and forever discharge the Releasee and their directors, officers, agents, employees, representatives, successors and assigns, administrators, executors, and all others from any and all responsibilities or liability from injuries or damages resulting from your participation in any activities or your use of equipment/facilities or machinery in the abovementioned activities. You do also hereby release all of those mentioned and any others acting upon their behalf from any responsibility or liability for any injury or damage to yourself, including those caused by the negligent act or omission of any of those mentioned or others acting on their behalf or in any way arising out of or connected with your participation in any activities of the Gym. This provision shall apply to ordinary acts of negligence but shall not apply to gross acts/omissions of negligence, willful or wanton acts/omissions, or those of an intentional/criminal nature.
D: *
Waiver and Release of Liability: Off-Site Special Events: D. From time to time, the Gym offers special events held outside of the normal Gym Facilities. By participating in those Off-Site Special Events, you hereby waive, release, hold harmless and forever discharge the Releasee and any promoting organizations, property owners, law enforcement agencies or other public entities, special districts and properties, and their respective agents, officials and employees from any and all responsibilities or liability from injuries or damages resulting from your participation in any activities you engage in during the Off-Site Special Event. This provision shall apply to ordinary acts of negligence but shall not apply to gross acts/omissions of negligence, willful or wanton acts/omissions, or those of an intentional/criminal nature.
E: *
Waiver and Release of Liability: Loss or Theft of Property: E. The Releasee are not responsible for lost or stolen articles. You should keep any valuables with you at all times while using the facilities. Storage space or lockers do not always protect valuables. Consequently, by executing this Agreement and any accompanying documents, you do hereby agree to assume all responsibility for your own property and that of any dependent(s) and to insure that property against risk of loss as you see fit. By the execution hereof, you expressly, on behalf of yourself and any dependents, do hereby knowingly agree to forego, waive, release, and prospectively give up any right to institute any claim or action against the Releasee relating to lost or stolen property, including property lost or stolen due to the negligent act or omission of the Releasee.
F: *
Waiver and Release of Liability: Payment & Termination: F. All payments are due on the 1st day of each month. Payments made after the 7th day of the month are subject to a $20 late fee. Gym privileges will be suspended if a monthly payment (plus applicable late charges) are not received by the 15th day of each month. Those individuals who are persistently late in paying fees will be asked to leave the Gym. You may terminate your membership by providing Vincent Mini with a 30-day written notice. If no notice is provided, you will be charged for one calendar month following your last day of attendance at the Gym
Membership Obligation *
I have read and understand my financial obligations, and I have received my package details sheet
START DATE *
PLEASE Indicate your preferred scheduled time
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Time
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G: *
Waiver and Release of Liability:Modifications, Waiver & Severability: This agreement may not be modified orally. A waiver of any provisions of this Agreement shall not be construed as a waiver of any other provision herein or as a consent to any subsequent waiver or modification. This Agreement shall be interpreted according to the laws of the State of California. If any part of this Agreement should ever be determined by a court of final jurisdiction to be invalid, the remaining portions hereof shall be deemed to be valid and enforceable.
Acknowledgement: *
By typing name below I acknowledge that I have read and received a completed copy of this Agreement and any of its Exhibits, and have been apprised of any Rules and Regulations of the Gym, which are incorporated herein by reference. I agree to be bound by the terms and conditions of the Agreement and the Rules and Regulations of the Gym, as same exist or as same may be amended from time to time hereafter. This Agreement shall be binding upon me and my spouse, my heirs, my estate, my executors, my administrators, and my successors and/or assigns, I realize that this Agreement is designed to prevent me and/or them from filing any personal injury or other lawsuit based upon ordinary negligence, including negligent battery, or even negligent wrongful death, loss of consortium, or any other similar lawsuit arising out of any injury to me which I or they may possess hereafter. The undersigned, on behalf of myself and my heirs, executors, administrators, successors, and assigns hereby agree to indemnify the Gym and all those hereby released and to hold them absolutely harmless, including attorneys' fees and litigation expenses (specifically including Releasee’ attorney's fees and litigation expenses reasonably necessary to successfully enforce this indemnification provision) if anyone, including the undersigned, should hereafter file suit against the Gym or those released hereby for any matter intended to be released by this Agreement, including claims based upon ordinary negligence such as but not limited to personal injury, wrongful death, loss of consortium, or other similar actions.
Your answer
Acknowledgement Date
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Consent *
Consent to treat, Waiver and Release of Liability: In agreeing to receive care provided by Mikla Dunning Physical Therapy Systems, PC (MDPT) and to use the facilities provided therefore by Mini's House of Pain located at 4990 Hillsdale Circle, El Dorado Hills, CA 95762. I agree as follows: I fully understand and acknowledge that (a) the activities in which I will engage as part of the treatment provided by MDPT and the equipment I may use as a part of that treatment have inherent risks, dangers, and hazards and such exists in my use of any equipment and my participation in these activities; (b) my participation in such activities and/or use of such equipment may result in injury or illness including, but not limited to bodily injury, disease, strains, fractures, partial and/or total paralysis, death or other ailments that, could cause serious disability; (c) these risks and dangers may be caused by the negligence of the representatives or employees of MDPT, Mini's House of Pain, the negligence of the participants, the negligence of others, accidents, breaches of contract, or other causes. By my participation in these activities and for use of equipment, I hereby assume all risks and dangers and all responsibility for any losses and/or damages whether caused in whole or in part by the negligence or the conduct of the representatives or employees of MDPT, Mini's House of Pain, or by any other person. I, on behalf of myself, my personal representatives and my heirs, hereby voluntarily agree to release, waive, discharge, hold harmless, defend, and indemnify MDPT, Mini's House of Pain and their representatives, employees, and assigns from any and all claims, actions or losses for bodily injury, property damage, wrongful death, loss of services or otherwise which may arise out of my use of any equipment or participation in these activities. 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 MDPT or Mini's House of Pain. Consent: I consent to and authorize MDPT (including students in training) to administer physical therapy treatment under the direction and supervision of the physical therapist. I understand and am informed that, as in the practice of medicine, physical therapy may have some risks. I understand that I have the right to ask about these risks and have any questions about my conditions answered 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 HAVE READ THE ABOVE WAIVER AND RELEASE AND BY SIGNING IT AGREE. IT IS MY INTENTION TO EXEMPT AND RELIEVE INTEGRATIVE PHYSIOTHERAPY LLC AND ELAN YOGA & FITNESS FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH BY ANY CAUSE.
Financial Agreement *
Package Plan
HIPPA Notice:
HIPAA FORM MIKLA DUNNING PHYSICAL THERAPY SYSTEMS, PC. (MDPT) This notice describes how information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Introduction At MDPT we are committed to treating and using protected health information about you responsibly. This Notice of Health Information Practices describes the personal information we collect, and how and when we use or disclose that information. It also describes your rights as they relate to your protected health information. This Notice is effective March 31th, 2003 and applies to all protected health information as defined by federal regulation. Uses and Disclosures The following are examples of ways we use your health information. 1. We use your health information to document and plan treatment, progress, planning, etc. 2. We use your health information for payment. For instance, we need to send health information including procedures done and diagnoses to your insurance company. 3. We use your health information for regular health operations. For example, our compliance officer regularly chooses medical records for audits. This practice ensures that we are constantly working towards improved quality and effectiveness. 4. There are services provided in our organization through contacts with business associates. Examples include assistants, billing and transcription services. 5. We may use or disclose information to notify or assist in notifying a family member, personal representative, or other person responsible for your care, your location, and general condition. The following are examples of other purposes for which SPT is permitted or required to disclose confidential information without the individual’s written authorization. 1. Uses and disclosures for public health activities; 2. Reporting victims of abuse, neglect, or domestic violence; 3. Disclosures for judicial and administrative proceedings; 4. Disclosures for law enforcement purposes; 5. Disclosures to avert a serious threat to health or safety; and 6. Uses and disclosures for specialized government functions. Separate Statements for Certain Uses or Disclosures MDPT may contact patients with appointment reminders, requests for the patient to contact MDPT for appointments, notices and letters concerning medical findings. MDPT may also contact the patient about treatments alternatives or other health related benefits and services that may be of interest to the individual. Individual Rights: Although your health record is the physical property of MDPT, the information belongs to you. You have: 1. The right to request restrictions on certain uses and disclosures of your information; 2. The right to revoke your authorization to use or disclose health information except to the extent that action has already been taken. 3. The right to receive confidential communications; 4. The right to obtain a copy or inspect your health information; 5. The right to amend protected health information; 6. The right to receive an accounting of disclosures of protected health information. MDPT’s Rights 1. MDPT has 30 days with which to comply with a patient’s request to review or copy their health information. MDPT is allowed an additional 30 days if the record is off site. MDPT may charge a fee for copying the health record. 2. The therapists have the right to review the record and remove any information that they deem to be harmful to either the patient or to another individual; 3. The patient will be supervised by MDPT staff during any review of the record. Supervision is allowed and required to prevent the removal or altering of the medical record. MDPT will charge staff time for this service. MDPT’s Duties 1. MDPT is required by law to maintain the privacy of confidential information and provide individuals with notice of its legal duties and privacy practices with respect to such information; 2. MDPT is required to abide by the terms of this Notice; and 3. MDPT reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all confidential information that it maintains. Revisions to this Notice will be posted in the patient waiting area. Complaints: Individuals may complain to MDPT’s Administrator in writing to address below. You may also contact the Secretary of the U.S. Department of Health and Human Services at 200 Independence Ave., S.W., Rm. 509F, HHH Building, Washington DC 20201. Please contact the MDPT administrator at 916-933-7246 for further information. I have received the Notice of Privacy Practices and I have been provided an opportunity to review it.
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