Pre-Employment Physical Informed Consent

Photo/Video Consent:

You authorize ACE Physio & Performance, PLLC to collect and publish photos and/or videos of your treatment.  Photographs taken during workshops, total body screen, initial evaluation, progress evaluation, and discharge summary can be used for postural comparison purposes and as educational tools.  These photos/videos could be used for promotional and informational marketing material.  By signing below you consent to the use of these photographs in a professional manner without any form of reimbursement. 

Visitor's Acknowledgment of Risks:

In consideration of the services of ACE Physio & Performance, PLLC their officers, agents, employees, and stockholders, and all other persons or entities associated with those businesses.

 

I agree as follows:

Although ACE Physio & Performance, PLLC has taken reasonable steps to provide me with appropriate equipment and skilled guides so I can enjoy an activity for which I may not be skilled, ACE Physio & Performance, PLLC has informed me this activity is not without risk. Certain risks are inherent in each activity and cannot be eliminated without destroying the unique character of the activity. These inherent risks are some of the same elements that contribute to the unique character of this activity and can be the cause of loss or damage to my equipment, or accidental injury, illness, or in extreme cases, permanent trauma or death. ACE Physio & Performance, PLLC does not want to frighten me or reduce my enthusiasm for this activity but believes it is important for me to know in advance what to expect and to be informed of the inherent risks. The following describes some, but not all, of those risks.

Functional movements such as pushing, pulling, and lifting weighted objects come with a potential risk of sprains, strains, and other injuries not listed here.

I am aware that a Pre-Employment Physical entails risks of injury or death to any participant. I understand the description of these inherent risks is not complete and that other unknown or unanticipated inherent risks may result in injury or death. I agree to assume and accept full responsibility for the inherent risks identified herein and those inherent risks not specifically identified. My participation in this activity is purely voluntary, no one is forcing me to participate, and I elect to participate in spite of and with full knowledge of the inherent risks. I acknowledge that engaging in this activity may require a degree of skill and knowledge different than other activities and that I have responsibilities as a participant. I acknowledge that the staff of ACE Physio & Performance, PLLC has been available to more fully explain to me the nature and physical demands of this activity and the inherent risks, hazards, and dangers associated with this activity. I certify that I am fully capable of participating in this activity. Therefore, I assume and accept full responsibility for myself, including all minor children in my care, custody, and control, for bodily injury, death, or loss of personal property and expenses as a result of those inherent risks and dangers identified herein and those inherent risks and dangers not specifically identified, and as a result of my negligence in participating in this activity. I have carefully read, clearly understood, and accepted the terms and conditions stated herein and acknowledge that this agreement shall be effective and binding upon myself, my heirs, assigns, personal representative, and estate and for all members of my family, including minor children.

Your signature below indicates that you agree with the above statements. You agree and acknowledge that a photocopy or PDF version of this signed agreement will be as valid as the original.  You agree that should you have any disputes with ACE Physio & Performance, PLLC that the state law will govern such disputes and that such disputes must be held at a court located in the county where you receive treatment.