WAIVER
Please read this waiver carefully. – Sign and submit buttons are below.
1. Release of Liability: I understand and accept the risks associated with physical exercise, physical therapy, chiropractic treatment and agree to release One Performance Institute from any liability for injuries or damages.
2. Assumption of Risk: I acknowledge that I am voluntarily participating in physical activities and therapies and assume the inherent risks associated with these activities.
3.Health Status Confirmation: I confirm that I am in good health and have no medical conditions that would prevent me from safely engaging in physical exercise. I agree to inform my practitioner of any conditions I have been diagnosed with.
4. Emergency Medical Consent: I authorize One Performance Institute to seek emergency medical treatment if necessary and release One Performance from any liability related to such treatment.
5. Photography and Likeness Release: I allow One Performance Institute to use photographs or videos taken during treatment for promotional purposes when taken by One Performance Institute staff, internal trainers or external trainers.
Consent to Physiotherapy Treatment: I understand that the primary goals of physiotherapy 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 physiotherapist to perform a physical assessment to enable them to develop an individualized treatment plan.
I understand that physiotherapy 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, therapeutic/performance taping and/or medical acupuncture.
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. Specifically, acupuncture involves the insertion of a single-use, sterilize, disposable needle through the skin into underlying tissues and can result in minor soreness, bleeding or bruising, nausea, fainting, infection, stuck or bent needles, shock convulsions, and possible perforation of internal organs. I understand that the latter 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 my physiotherapist at One Performance Institite to perform an assessment with the purposes of formulating an individualized, patient-centred treatment plan. In turn, they will provide me with 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.
Consent to Chiropractic Treatment: I understand that the primary goals of chiropractic 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 chiropractor to perform a physical assessment to enable them to develop an individualized treatment plan.
I understand that chiropractic treatments may include adjustment, manipulation and mobilization of the spine and other joints of the body, soft tissue techniques such as massage, and other forms of therapy including, but not limited to, electrical or light therapy and exercise. Other treatments may include heat, ice, therapeutic/performance 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. Possible risks include: temporary worsening of symptoms, skin irritation or burn, sprain or strain, rib fracture, injury or aggravation of a disc, and stroke. 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. Alternative to chiropractic treatment may include consulting with other health professionals. Your chiropractor may also prescribe rest without treatment or exercise with or without treatment.
I grant permission to my chiropractor at One Performance to perform an assessment with the purposes of formulating an individualized, patient-centred treatment plan. In turn, they will provide me with 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.
Consent to Kinesiology Treatment: I understand that the primary goals of kinesiology treatments are to help reduce my pain and improve my performance, mobility, strength, endurance, function, and quality of life.
I understand that there are inherent risks, dangers, hazards, and liabilities to all participating in treatment. I understand that the treatment may include physical activity in the form of a variety of sports, weight training, gym training, and recreational activities. I confirm that I am physically and mentally capable of participating in treatment. I understand the potential for permanent paralysis and death, and while particular rules, equipment, and personal discipline may reduce the risk, the risk of serious injury does exist and,
I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of the releases or others and assume full responsibility to my participation; and I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately.
Consent to Registered Massage Therapy: I understand that the primary goals of registered massage therapy (RMT) 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 RMT to perform a physical assessment to enable them to develop an individualized treatment plan.
I understand that RMT 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 and/or ice.
I acknowledge and understand that my clothing may be left on or removed at my discretion, and I acknowledge that it is completely in my power to stop or modify my treatment at any time, including during a massage. I agree to all of the above and confirm that I have been given a chance to ask any questions related to the treatment and confirm that all of my questions have been answered to my satisfaction. I agree to comply with the rules set out herein and I give my full informed consent for receiving massage therapy.
Please sign and submit this waiver in order to receive treatment.