In agreeing to receive care provided by Elevate Wellness Solutions LLC (“Elevate”) and to use the facilities provided therefore by Elevate Wellness Solutions LLC home office located at 504 W. Kem Road, Marion, Indiana, 46952,  (or otherwise mutually agreed upon location) 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 Elevate and associates are physical medicine activities and equipment may be uses as a part of that treatment
(b) equipment used for treatments have inherent risks, dangers, and hazards and such exists in my use of any equipment and my participation in these physical medicine activities;
(c) my participation in such physical medicine activities and/or use of such equipment may result in injury or illness including, but not limited to bodily injury, disease, strains, sprains, fractures, partial and/or total paralysis, death or other ailments that could cause serious disability;
(d) these risks and dangers may be caused by the negligence of the representatives, employees, and/or associates of Elevate.  The negligence of the participants, the negligence of others, accidents, breaches of contract, or other causes may result in injury and/or emotional distress. 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 Elevate, or by any other associated entity.
(e) equipment and treatment strategies may include (but are not limited to) the following:
electrophysical agents, Astym Therapy, Dry Needling, joint mobilizations, mobilization, strengthening, and stretching or more not included here

I, on behalf of myself, my personal representatives and my heirs, hereby voluntarily agree to release, waive, discharge, hold harmless, defend, and indemnify Elevate Wellness Solutions LLC 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 Elevate.

I HAVE READ THE ABOVE WAIVER AND RELEASE AND BY SIGNING IT AGREE. IT IS MY INTENTION TO EXEMPT AND RELIEVE ELEVATE FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH CAUSED BY NEGLIGENCE OR ANY OTHER CAUSE.  I ALSO ACKNOWLEDGE THAT TYPING MY NAME WILL ACT AS A REPLACEMENT OF A SIGNATURE.

(Legal representatives of patients who may be legally unable to make medical decisions on their own behalf; such as minors or individuals who have power of attorney, must have a legal guardian sign this form prior to treatment.)