Patient/Client Consent

I hereby RELEASE, WAIVE, DISCHARGE, and HOLD HARMLESS Goode Sports Medicine and Wellness LLC, its owner, partners and employees from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or related to any loss, damage, or injury, that may be sustained by any person providing services, while using the equipment or due to the use of the equipment at Goode Sports Medicine and Wellness. 

I voluntarily consent for and authorize services as my medical provider, his/her assistants, or designees (collectively called “the providers”) may deem necessary or advisable.  This care may include, but is not limited to, assisted stretch, IV vitamin hydration, compression therapy, detox sauna blanket, dry needling, laser lipolysis, lymphatic drainage massage, post PT rehabilitation, radio frequency skin tightening, sports injury assessment, sports massage, Thai massage, ultrasonic cavitation, NeuFit – neurological fitness and StemWave (shockwave therapy), etc.  I have the right to refuse any services advised.  I authorize my provider(s) to perform other additional or extended services in emergency situations if it may be necessary or advisable in order to preserve my life or health. I understand that my care is directed by my provider(s) and that other personnel render care and services to me according to the provider(s) instructions.

I acknowledge that no guarantees or promises have been made to me with respect to results of such procedure(s) or treatment(s).

I am aware that I may stop treatment at any time.

I am aware that I am paying for services "out of pocket”, and I am responsible for all balances due.

By signing below, I agree that I have been fully oriented to the treatment that is being provided to me as a patient/client. My signature constitutes my acknowledgment that (A) I have read, understand, and fully agree to the foregoing CONSENT, (B) the proposed usage of the rehabilitation and recovery equipment has been satisfactorily explained to me and I have all of the information I desire and (C), I hereby give my authorization and consent. This CONSENT shall stand as long as I utilize the services and equipment at Goode Sports Medicine and Wellness and its partners (Rapid Recovery Solutions LLC and Phit Nutrition LLC) now and in the future. I have been given the instructions for proper use of the facilities written or verbally and do so at my own risk and hereby release Goode Sports Medicine and Wellness and its partners (Rapid Recovery Solutions LLC and Phit Nutrition LLC) from any damage or harm that I might incur due to use.  

IN SIGNING THIS RELEASE, I ACKNOWLEDGE AND REPRESENT THAT I have read and understand the foregoing Waiver of Liability, release and Hold Harmless Agreement, I am at least eighteen (18) years of age and fully competent; and I execute this Release for full, adequate, and complete consideration fully intending to be bound by same. Furthermore, I agree that I will comply with all instructions and that I am using these services at my own risk.

DO NOT SIGN UNLESS YOU HAVE READ AND THOROUGHLY UNDERSTAND THIS FORM. You have the right to withdraw consent for this procedure at any time before it is performed.

Minors require a parent/guardian signature.