Movement With

WAIVER, RELEASE, AND ASSUMPTION OF RISK FORM

This form is an important legal document.   This is an explanation of the risks you are assuming by performing a fitness and/or physical therapy program.  Please ensure that you read and understand this completely.  After you have done so, please type your name in the appropriate area as a signature and date.

WAIVER, INFORMED CONSENT, AND COVENANT NOT TO SUE

I have volunteered to participate in a program of physical fitness training and/or physical therapy under the direction of Shaun Logan, PT, DPT.  The program will include, but many not be limited to, mobility/flexibility training, cardiovascular training, balance, dynamic motor control, strength training. In consideration of Shaun Logan, PT, DPT agreement to instruct, assist, treat, and train me, I do here and forever release and discharge and hereby hold Shaun Logan, PT, DPT harmless from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected with my participation in this or any fitness and/or physical therapy program including any injuries resulting there from.  THIS WAIVER AND RELEASE OF LIABILITY INCLUDES, WITHOUT LIMITATION, INJURIES WHICH MAY OCCUR AS A RESULT OF (1) EQUIPMENT THAT MAY MALFUNCTION OF BREAK (2) ANY SLIP, FALL, DROPPING OF EQUIPMENT.

ASSUMPTION OF RISK

I hereby acknowledge that I have signed up for a unique combination of fitness training and physical therapy.  My session will be tailored to my needs – ranging from more physical therapy focus to more fitness training focus.  I RECOGNIZE THAT EXERCISE MIGHT BE DIFFICULT AND STRENUOUS AND THAT THERE ARE DANGERS INHERENT WITH EXERCISE/FITNESS FOR SOME INDIVIDUALS.  I acknowledge the possibility of certain unusual physical changes during fitness and movement training does exist.  These changes could include, but are not limited to, abnormal changes to blood pressure, fainting, irregularities in heartbeat, heart attack, and, in rare instances, death.

I understand that as a result of my participation in a fitness/movement training program, I could suffer an injury or physical disorder that could result in becoming partially or totally disabled and incapable of performing any gainful employment or having a normal social life.

I recognize that an examination by a licensed physician is recommended prior to involvement in a fitness or treatment program with Shaun Logan, PT, DPT.  I also recognize that direct access physical therapy is legal in Massachusetts, which allows licensed Doctor of Physical Therapy to assess and treat without physician referral. At the onset of a medical problem outside of a physical therapy scope of practice, you will be referred out to another health care professional as appropriate, but you are responsible for your own healthcare and healthcare related decisions.

I acknowledge and agree that I assume the risks associated with any and all activities and/or exercises in which I participate.

I acknowledge and agree that no warranties or representations have been made to me regarding the results I will achieve from this program.  I understand that results are individual and will vary.

FINANCIAL INTEREST

I ACKNOWLEDGE THAT I HAVE BEEN ADVISED BY MY PHYSICAL THERAPIST THAT HE HAS A FINANCIAL OR OWNERSHIP INTEREST IN THE FACILITY OR ENTITY TO WHICH HE HAS REFERRED ME, AND THAT HE HAS ADVISED ME THAT I AM FREE TO CHOOSE ANOTHER FACILITY OR ENTITY TO PROVIDE THE SERVICE, DRUG, DEVICE OR EQUIPMENT.

TREATMENT WITH SHAUN LOGAN, PT, DPT MAY INCLUDE A RECOMMENDATION FOR FURTHER DIAGNOSTIC TESTING, FOR VARIOUS FORMS OF THERAPY OR TREATMENT, OR FOR DRUGS OR DEVICES. YOUR PHYSICAL THERAPIST IS REQUIRED TO DISCLOSE TO YOU ANY FINANCIAL INTEREST HE HAS IN TREATMENT FACILITIES, TESTING LABORATORIES, MEDICAL EQUIPMENT SUPPLIES, PHARMACEUTICAL COMPANIES AND PHARMACIES TO WHICH HE REFERS YOU. HE MUST ALSO ADVISE YOU THAT YOU ARE FREE TO CHOOSE ANOTHER FACILITY OR ENTITY TO PROVIDE THE SERVICE, DRUG, DEVICE OR EQUIPMENT. (ACT 66-1988)

TREATMENT/TRAINING

I hereby acknowledge that I have signed up for a unique combination of fitness training and physical therapy.  My session will be tailored to my needs – ranging from more physical therapy focus to more fitness training focus.  Shaun Logan, PT, DPT does not put a timeline on reducing pain or injuries, as this varies for each individual.

I hereby acknowledge that I have been advised that if appropriate to my treatment or training my care may require the therapist, Shaun Logan, PT, DPT, (for treatment) and/or trainer (for cues and teaching purposes) to appropriately place his or her hands on my head, face, neck, shoulders, legs, hips, feet, lower back, chest, groin or buttocks areas.  I hereby consent and agree to the appropriate use of such treatment and fitness training techniques.  If I feel uncomfortable or that the methods being uses are inappropriate at any time, I will alert Shaun Logan, PT, DPT immediately. Soreness or increase in symptoms for up to, but not limited to, 2 days following treatment and/or training is common.

I agree to alert Shaun Logan, PT, DPT of all and any allergies, illnesses, injuries, etc. that may affect my health or outcome while working with Shaun Logan, PT, DPT.

I further understand and agree that for therapy and training to be effective, I must keep my scheduled appointments unless unexpected circumstances prevent me from doing so.  In such an event, I will contact Shaun Logan, PT, DPT as soon as possible.  I agree to be honest with Shaun Logan, PT, DPT about my compliance, intentions, and to work hard to bet the best possible results.

I ACKNOWLEDGE THAT I HAVE THOROUGHLY READ THIS WAIVER AND RELEASE AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY.  BY SIGNING THIS DOCUMENT, I AM WAIVING ANY RIGHT I OR MY SUCCESSORS MIGHT HAVE TO BRING A LEGAL ACTION OR ASSERT A CLAIM AGAINST Shaun Logan, PT, DPT.

By entering your name below you are “signing” that you accept consent to treatment and/or training and the working relationship with Shaun Logan, PT, DPT. I acknowledge and agree that I assume the risks associated with any and all activities and/or exercises in which I participate. I acknowledge and agree that no warranties or representations have been made to me regarding the results I will achieve from this program.  I understand that results are individual and will vary.