In agreeing to receive care with Elevated Physio Solutions I agree as follows:

I fully understand and acknowledge that

(a) Protocols received are recommendations; in which that can be adjusted or customized by the patient or provider as necessary.

(b) Injury assessments are based on collegiate education/evidence-based research, objective assessment tools, and special tests.

(c) X-rays or MRI’s may be necessary for the most accurate diagnosis; the cost is the patient’s responsibility. I recognize, understand, and agree that any medical imaging that may be needed will be shared with the providers at Elevated Physio Solutions.

(d) I hereby assume all risks and dangers and all responsibility for any losses and/or damages whether caused in whole or in part by the negligence or the conduct of the employees of Elevated Physio Solutions.

(e) I grant permission for findings and treatment methods to be documented by the provider.

(f) I know that I have the right to choose what treatments I do or do not receive, in addition to withdrawing from treatments at any time;

(g) I recognize that my participation in the activities covered by this agreement is contingent upon my signing and returning this Informed Consent and waiver & release. I, on behalf of myself, my personal representatives and my heirs, hereby voluntarily agree to release, waive, discharge, hold harmless, defend, and indemnify Elevated Physio Solutions and its employees, and assigns from any and all claims, actions or losses arising from bodily injury, property damage, wrongful death, loss of services, or any other causes 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, both present and future, for negligent acts or other conduct by the employees of Elevated Physio Solutions. 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.

Consent:

I consent to and authorize Elevated Physio Solutions to administer treatment under the direction and supervision of the Athletic Trainer. I understand and am informed that, as in the practice of medicine, athletic training may have some risks. I acknowledge that I have the right to ask about these risks and have any questions about my conditions addressed prior to treatment. I know it is up to me to inform the athletic trainer of any health conditions or allergies I have, as well as medications I am taking.

I HAVE READ THE ABOVE INFORMED CONSENT AND WAIVER & RELEASE, AND I AGREE TO ITS TERM BY SIGNING IT. I INTEND TO EXEMPT ELEVATED PHYSIO SOLUTIONS FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH BY ANY CAUSE.