In case of an emergency:

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Please read the information below before signing. 

Card on File Authorization

 

I authorize Healing Motion Physical Therapy, Inc. to securely store my credit card information on file for the purpose of processing any outstanding balances prior to each performance training appointment or before the completion of any programming for the current month. Additionally, if I am enrolled in a monthly programming subscription through Train Heroic and carried out by a Healing Motion coach, I consent to Healing Motion Physical Therapy, Inc. charging my card on the 1st of each month until either party provides notice of cancellation.

Appointment Policies

Appointments
Attendance at all scheduled appointments is extremelyimportant. Our appointments are on a 45-minute basis. If a scheduling conflict occurs, please call us as soon as possible. We may be able to use your time for another client and reschedule you for a more convenient time.

Appointment Policies
By signing below, you acknowledge that the responsibility for attending appointments that are scheduled is yours. If desired, a reminder card will be given when the appointment is scheduled. Additionally, an appointment reminder will be sent to you prior to each appointment. The following guidelines will be used for no shows and late cancellations under 24 hours prior to any appointment:
1st Occurrence: Grace is given. We are all human. Things happen.
2nd Occurrence: A reminder of our policy will be given.
3rd Occurrence: All upcoming appointments will be cancelled and given to a wait-listed patient.
The occurrence expires 90 days from when the occurrence happened. Three occurrences in any 90-day
period will result in the cancellation of all remaining appointments.
Late Arrivals: If you are 10 minutes late or more, a $30 fee will be applied and collected before the
appointment can begin or the appointment may be cancelled and counted as an occurrence for the
90-day period.

Monthly Subscription Cancellations
For clients enrolled in monthly programming subscriptions, a 30-day notice is required for cancellation. If you wish to cancel your subscription, please notify us at least 30 days before the next billing cycle, which begins on the 1st of each month. Refunds will not be issued for late notice of a monthly subscription cancellation.

Photo/Video Consent and Release (optional)

I, being of legal age, hereby grant permission, and have the right to grant permission, to Healing Motion Physical Therapy, Inc. (HMPT) to use the photo and/or video of me. I understand that this consent is perpetual, that it may not be revoked, and that it is binding on my heirs and assigns.

I hereby grant HMPT the perpetual, absolute and irrevocable right and permission to use, reproduce, edit, exhibit, project, display, copyright, publish and/or resell photographic pictures and/or moving pictures and/or videotaped images that I took and to circulate the same in all forms and media (including, but not limited to: social media (FaceBook, Twitter, etc.), YouTube and on HMPT’s website, any publications, any advertising/promotion, videotapes, audio tapes, compact discs, computer files and photographs) for educational, trade, all forms of advertising/promotion or any lawful purpose. I waive all claims to compensation and damages.

I hereby waive any right that I may have to inspect and/or approve the finished product or products or the editorial, advertising or printed copy that may be used in connection there with and any right that I may have to control the use to which said product, products, and copy may be applied.

I acknowledge and agree that I have complied with all state and federal laws regarding privacy, including the Health Insurance Portability and Accountability Act (HIPAA) Standards for Privacy of Individually Identifiable Health Information (Privacy Standards) and have obtained any necessary authorizations and consents.

I hereby release, discharge and agree to save harmless HMPT, its affiliates, components, employees, sponsors, agents and assigns of the foregoing, from any liability or claimed liability in connection with the aforementioned use of the photograph, videotape, name, image, likeness or performance.

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Please select all medical conditions you currently have or have had in the past. 

Upload OR type out your current medication and supplement list below.

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