Accuracy of Information
I certify that all information given to my provider are true to the best of my knowledge and belief and I understand that they are not liable in the event that the facts are found to be falsified or misleading.
Privacy & Sharing Information
I give authorization to collect my personal and medical information. In addition, I authorize communication to my Primary Care Physician and/or any referring professional as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission.
Physical Therapy Treatment without Referral Disclosure
I understand that physical therapy treatment without a referral will be based on the physical therapist’s examination and evaluation of my current condition which may result in identification of movement and mobility dysfunction.
I understand that the physical therapist will not diagnose an illness or disease, and that physical therapy is not a substitute for a medical diagnosis.
I understand that if a medical diagnosis has already been established by a qualified healthcare practitioner, the physical therapist will take it into consideration during the evaluation process.
I understand that the physical therapy plan of care developed by the physical therapist may not be based on radiological imaging. I understand that if images have previously been obtained, the physical therapist may use the information as part of the evaluation process.I understand that if the physical therapist identifies a need for radiological imaging, the physical therapist may recommend that radiological imaging be obtained.
I understand that my health insurance may not cover physical therapy services if provided without a referral from a qualified healthcare practitioner.
Consent to Treatment
I voluntarily consent to receive physical therapy treatment provided by Made to Move, LLC (Made 2 Move). I acknowledge that the nature of the treatment has been explained to me, including any potential risks and benefits. I understand that while the goal of treatment is to improve my physical condition, no guarantees can be made regarding outcomes.
Acknowledgment of Risks
I acknowledge that I am participating in Sports Medicine and Physical Therapy services provided by Made to Move, LLC (Made 2 Move) which may involve physical activity, exercises, and manual therapy techniques that have inherent risks involved with them. The risks from participating in these treatments include, but are not limited to, falls, sprains, strains, discomfort, redness of skin, soreness, bruising, or more serious injuries as well as any risks that may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained, or controlled by them, or because of their possible liability without fault. I voluntarily assume all of the risks associated with my participation with this event/service.
Release of Liability
In consideration of being permitted to participate in Sports Medicine Physical and Physical Therapy services, I hereby waive, release, and discharge Made to Move, LLC (Made 2 Move), its staff, volunteers, and agents from any and all claims, demands, or causes of action for personal injury, property damage, or wrongful death that may arise from my participation, even if caused by the negligence of the released parties. I hold harmless and promise not to sue the entities or persons mentioned in this paragraph from any and all liabilities or claims made as a result of participation in this activity, whether caused by the negligence of release or otherwise. I acknowledge that Made to Move, LLC (Made 2 Move), and their directors, officers, clinicians, volunteers, representatives, and agents are NOT responsible for the errors, omissions, acts, or failures to act of any party or entity conducting a specific activity on their behalf.
Photo/Video Release
I hereby grant Made to Move, LLC (Made 2 Move) permission to use my likeness in a photograph, video, or other digital media (“photo”) in any and all of its publications, including web-based publications, without payment or other consideration.
I understand and agree that all photos will become the property of Made to Move, LLC (Made 2 Move) and will not be returned.
I hereby irrevocably authorize Made to Move, LLC (Made 2 Move) to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo.
I hereby hold harmless, release, and forever discharge Made to Move, LLC (Made 2 Move) from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.
I acknowledge that I have read and understand all the information and terms outlined in this document. I agree to the items stated herein.