Consent
I, {name21}, have voluntarily elected to receive physical therapy consultation/health coaching services through Jason Hooper, PT, DPT, OCS, SCS. I recognize that it may involve strenuous physical activity including, but not limited to, muscle strength and endurance training, cardiovascular conditioning and training, and other various fitness activities. It may also include manual therapy and other hands-on aspects of treatment.
Health Statement
I hereby affirm that I am in good physical condition and do not suffer from any known disability or condition which would prevent or limit my participation in this program. I hereby agree that I am participating at my own risk. I understand that it is my sole responsibility to participate in exercises that are appropriate for the current status of my health. If I have any questions or concerns about whether or not a particular activity is appropriate to my current health status, I understand it is my responsibility to ask my doctor if this activity is appropriate before I participate in such activity.
Indemnification
I agree to indemnify and hold harmless Jason Hooper, PT, DPT, OCS, SCS, and their assigns, from any and all claims, costs, liabilities, and expenses, including attorney's fees, arising out of or in connection with my participation in the physical therapy consultation services provided. I understand and acknowledge that this indemnification extends to any claims made by third parties related to my participation in the program.
The Wall Climbing Gym
I understand that physical therapy activities are led by independent practitioners who are not employees or agents of The Wall Climbing Gym. The Wall Climbing Gym is not responsible in any manner for the exercises or treatments performed.
Online Appointments
If I am receiving an electronic consultation (health coaching), I acknowledge that certain aspects of the evaluation will be limited and may limit the capacity of the consultation.
Health Risks
I understand that any exercise or fitness activity involves a risk of injury, as well as abnormal changes in blood pressure, fainting, and a remote risk of heart attack, stroke, other serious disability or death. I am accepting such risks and volunteering to participate with full understanding of the dangers involved. In consideration of my participation in this program, I hereby waive and release Jason Hooper, PT, DPT, OCS, SCS, and assigns, from any and all claims, costs, liability and expense for any injury, loss or damage whether known, anticipated or unanticipated arising from my voluntary participation and enrollment.
Resharing
*I acknowledge that any rehab, training, or informational documents shared with me by Jason Hooper are not to be reshared or distributed in any manner without the written consent of Jason Hooper. *
Acknowledgement
*I Acknowledge that I have thoroughly read this form in its entirety and fully understand it. I understand that it contains a release of liability.
Rights
By signing this document, I am waiving certain rights I or my successors might have to bring to a legal action or assert a claim against Jason Hooper, PT, DPT, or The Wall Climbing Gym.*