Voluntary Consent for Participation and Consent Waiver
Patient Parent/Guardian Name: *
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Patient Parent/Guardian Phone Number: *
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Date: *
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I give my consent to receive Speech/Language/Feeding/Swallowing services and/or other exercises and activities and acknowledge and agree that it is at my own risk. *
Required
I am responsible for the health and safety with respect to such services and acknowledge that receipt of the services from Mealtime Connection may result in bodily injury or death. The decision to receive services is voluntary, and I know of, understand and assume any and all the risks associated therewith; waive and release Mealtime Connection, my therapist, and all staff, affiliates, contractors from any and all liability, past, present, and future relating to this therapy. *
Required
Medical Care: It is understood that the services offered in the past, present, or future are not a substitute for medical care and there are no existing injuries, illnesses or conditions that could prohibit therapy because it could cause further damage. *
Required
Waiver of Liability
This agreement releases KMF Consulting LLC. dba Mealtime Connection from all liability, claims, demands, and causes of action now or in the future, relating to injuries that may occur during or after my child’s participation in therapy or other activities, at 14503 Houghton St. Chesterfield VA 23832 or at the child’s home or other setting. By signing this agreement, I agree to hold KMF Consulting LLC. dba Mealtime Connection entirely free from any liability, including financial responsibility for illnesses or injuries incurred, regardless of whether illnesses or injuries are caused by negligence. If other dependents accompany the patient the health and safety of those individuals are solely the responsibility of the individual (if 18 years of age or older) or the parent/guardian. I also acknowledge the risks involved in speech/language/feeding/swallowing therapy. I swear that I am participating voluntarily, and that all risks have been made clear to me. Additionally, I do not have any conditions that will increase my likelihood of experiencing injuries while engaging in this activity. I acknowledge that no guarantees or assurances have been made to me/my child concerning the results intended from treatment. By signing below I forfeit all right to bring a suit against KMF Consulting LLC. dba Mealtime Connection for any reason. In return, I will receive services. I will also make every effort to obey safety precautions as listed in writing or as explained to me verbally. I will ask for clarification when needed. *
Required
I hereby acknowledge and accept my FULL NAME typed below irrevocably as my electronic signature and affirm that I have read and fully understand the above statements. *
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