INFORMED CONSENT FOR ATHLETIC THERAPY

Iunderstand that the primary goals of athletic therapy treatments are to help reduce my pain and improve my performance, mobility, strength, endurance, function and quality of life. In order to achieve these goals, it is necessary for my athletic therapist, MICHAEL CHAN to perform a physical assessment to enable them to develop an individualized treatment plan.

understand that athletic therapy treatments may include an individualized exercise prescription and various forms of manual therapy techniques such as mobilization, manipulation, soft tissue release and stretches. Other treatments may include heat, ice, and therapeutic/supportive taping.

While individualized treatment plans are formulated to benefit me, I understand that there are small possibilities of risks or complications that may result from the above listed treatments. I understand these are extremely rare occurrences and I will have the opportunity to discuss these risks, and the nature and purposes of all my treatments with my treatment provider, and consent to treatment at that time. I am aware that I may withdraw this consent and discontinue treatment at any time.

I grant permission to the athletic therapist, MICHAEL CHAN, to perform an assessment with the purpose of formulating an individualized, patient-centered treatment plan. In turn, they will provide me understandable information on my clinical findings, short and long term goals, the treatment being suggested, significant risks, benefits of treatment, possible alternatives to this treatment and the potential risks of forgoing care.

| grant permission to the athletic therapist, MICHAEL CHAN, to communicate with any health care professional that rehabilitation of my condition may indicate, including release information regarding my condition and my ability to return to normal activity or work to my insurance company or their representative.

I understand the conditions and information provided above and give my consent for Athletic Therapy assessment/treatment to the above authorizations.