Please Fill Out Our Consent Form

We help active adults get out of pain, without leaving the gym.

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Consent to Treat/Waiver of Liability

I acknowledge that my physical therapist has informed me of my diagnosis, prognosis and the potential risks and benefits of all recommended interventions in my proposed plan of care and I have been given an opportunity to have all my questions answered. I hereby agree to participate in and consent to receive the physical therapy interventions recommended by my physical therapist (PT) as outlined in my treatment plan. I understand that the response to different physical therapy interventions varies from person to person and sometimes treatment interventions may result in increased pain, an aggravation of existing symptoms or a new injury. Therefore, I agree to inform my PT of any change in my symptoms and function so my treatment plan can be adjusted accordingly. I understand that I may decline any intervention at any time by informing my PT of my desires/concerns and that my refusal may result in a termination of my treatment if my PT determines that there are no other treatment alternatives or the refused intervention is essential to meeting my goals. I also understand that although we have set rehabilitation goals, my PT has made no guarantees that any particular outcomes will result from the therapy interventions.

I, on behalf of myself, my personal representatives and my heirs, hereby voluntarily agree to release, waive, discharge, hold harmless, defend, and indemnify Pinnacle Movement and Performance, and its 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 that I may have presently or in the future for the negligent acts or other conduct by the representatives or employees of Pinnacle Movement and Performance. I understand that I may show this INFORMED CONSENT and WAIVER & RELEASE OF LIABILITY to, and consult with, my own independent legal counsel before signing.

I have read this consent form, understand the benefits and risks involved in physical therapy, and agree to fully cooperate and participate in the proposed physical therapy interventions in the established plan of care. If I DO NOT want the services listed below performed on myself and/or my child, I will check the following indicating I DO NOT approve of the following services:

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THIS IS HEALTH CARE

DONE DIFFERENTLY.

Call or Text Now at

(561) 794-3006

Boynton Beach, Fl

3600 S Congress Ave Suite

Boynton Beach, FL 33426

MEDICAL DISCLAIMER:

All information on this website is intended for instruction and informational purposes only. The authors are not responsible for any harm or injury that may result. Significant injury risk is possible if you do not follow due diligence and seek suitable professional advice about your injury. No guarantees of specific results are expressly made or implied on this website.