Consent to Treat
Please read the Consent to Treat document and the Dry Needling (DN) Consent forms below and provide your full name below to serve as your electronic signature:
I, the undersigned patient, in receiving treatment and other services from Precision Physical Therapy, LLC (”Provider”) located at the Club facility known as River Valley Club, LLC at 33 Morgan Drive, Lebanon, NH 03766 (the "Club"), hereby acknowledge that the relationship between the Club and Provider is strictly that of landlord and tenant, respectively. I further acknowledge that neither the Club nor any person or entity affiliated with the Club has any responsibility or liability for any injuries, claims or damages arising from any treatment or other services performed by Provider. In addition, I understand that I might have access to use certain areas of the Club under the direction of the Provider and agree to the following:
1. Assumption of Risk: I understand that engaging in physical exercise and physical therapy includes an inherent risk of minor or major life threatening injury to persons and property, and death, including, but not limited to, injury arising from or relating to my participation in any supervised or unsupervised personal training or instruction conducted in or outside the Club. I hereby expressly agree to assume full responsibility for all bodily injury, death, property damage, and theft or loss of personal property, that might result from my use of the Club, equipment, services, programs, and personal training or instruction, no matter what causes such injury, damage or loss, including the active or passive negligence of the Club, its employees, agents, or independent contractors.
2. Potential Benefits of Treatment: decreased pain, increased muscle strength, endurance, flexibility, improved body posture, movement and alignment. Potential Risks: during treatment there exists a potential for numerous side effects including but not limited to muscle soreness or stiffness; numbness, tingling, or other paresthesias; muscle tears; bony fractures; paralysis; abnormal blood pressure, cerebrovascular accidents, fainting, disorders of heartbeat, and instances of heart attack and death. I assume all of the foregoing risks, and accept personal responsibility for any damages or other injury I might suffer. I am satisfied with my understanding of common risks and complications of the evaluation and treatment.
3. Waiver and Release of Liability: By my execution of this Agreement, I hereby waive any claims or rights that I may have hereafter against River Valley Club, the Club and its respective owners, affiliates, officers, directors, employees, independent contractors and agents (collectively, the "releasees") and agree to release and hold the releasees absolutely harmless from any and all claims, demands, injuries (including death), damages, losses, liabilities, actions, suits, or causes of action to persons or property, present and future arising from or related to my use of the Club, including the equipment, services programs, and personal training or instruction conducted inside or outside the Club, whether caused by the negligence of the releasees, except as to such claims which may arise from the gross negligence or willful misconduct of the releasees. I acknowledge that I have carefully read this Waiver and Release of liability and fully understand it is a release of liability.
4. I, on behalf of myself, my personal representatives and my heirs, hereby voluntarily agree to release, waive, discharge, hold harmless, defend, and indemnify Precision Physical Therapy, LLC, River Valley Club, LLC and their representatives, employees, and assigns from any and all claims, actions or losses for bodily injury, property damage, wrongful death, loss of services or otherwise 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 or actions that I may have presently or in the future for the negligent acts or other conduct by the representatives or employees of River Valley Club, LLC.
5. Consent: I consent to and authorize Precision Physical Therapy, LLC to administer physical therapy treatment under the direction and supervision of the physical therapist. I understand and am informed that, as in the practice of medicine, physical therapy may have some risks. I understand that I have the right to ask about these risks and have any questions about my conditions answered prior to treatment. I know it is up to me to inform the physical therapist/staff about any health problems or allergies I have, as well as medications I am taking.
I HAVE READ THE ABOVE WAIVER AND RELEASE AND BY SIGNING IT AGREE. I INTEND TO EXEMPT AND RELIEVE PRECISION PHYSICAL THERAPY, LLC AND RIVER VALLEY CLUB FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH BY ANY CAUSE.
6. NOTICE TO MEDICARE PATIENTS: Precision Physical Therapy, LLC provides only maintenance and wellness services to Medicare recipients, NOT medically necessary covered services. I acknowledge that Precision Physical Therapy, LLC is not a Medicare provider and neither the patient nor Precision Physical Therapy, LLC is allowed to bill Medicare or any secondary insurance provider for services rendered. NEITHER A BILL FOR PAYMENT NOR RECEIPT FOR REIMBURSEMENT MAY BE SUBMITTED TO MEDICARE OR SECONDARY INSURANCE.
Dry Needling (DN) Consent Form
Dry Needling involves placing a small needle into myofascial trigger points in order to stimulate a healing response in painful musculoskeletal conditions. Dry needling is not acupuncture or Oriental Medicine; that is, it does not have the purpose of altering the flow of energy (“Qi”) along traditional Chinese meridians for the treatment of diseases. Dry needling is a modern, science-based intervention for the treatment of pain and dysfunction in orthopedic conditions.
Like any treatment, there are possible complications. While these complications are rare in occurrence, they are real and must be considered prior to giving consent to treatment.
Risks of the procedure: Dry needling is very safe; however serious side effects can occur in less than 1 per 10,000 (0.01%). The most serious risk associated with DN is accidental puncture of a lung (pneumothorax). If this were to occur, it may likely only require a chest x-ray and no further treatment. The symptoms of shortness of breath may last for several days to weeks. A more severe lung puncture can require hospitalization and re-inflation of the lung. This is a very rare complication and in skilled hands should not be a concern.
Other risks may include infection or damage to internal organs. These are extremely rare events and have been reported in medical literature to occur in less than 1 in 200,000. As the needles are very small and do not have a cutting edge, the likelihood of any significant tissue trauma from DN is unlikely. Only single use, disposable needles will be used.
You should expect some temporary mild soreness post needling. Minor bruising may occur and is considered normal. The feeling of drowsiness, tiredness or dizziness may occur after needling but is rare(1-3% of patients).
Please indicate your answer to the questions below:
