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Consent Form

Informed Consent - Free Releaseology Session

Your FREE session includes a very brief look into your medical history and physical therapy treatments in order to address your symptoms. Releaseology, LLC and Sara Becker will focus on stretching for today's event but may use a combination of physical therapy techniques such as stretching, massage, mobilizations and more techniques in order to improve your function. Please note that all of these techniques will require hands-on and sometimes full body contact by your PT in order to facilitate the technique and by signing below, you acknowledge that you consent to the full body contact with your PT and will report if you are uncomfortable at any time, to give the PT the feedback to readjust.

As with all forms of medical treatment, there are benefits and risks involved with physical therapy. Since the physical responses to a specific treatment can vary widely from person to person, it is not always possible to accurately predict your responses to a certain therapy modality or procedure. I am not able to guarantee precisely what your reactions to a particular treatment might be, nor can I guarantee that the treatment provided will help the condition you are seeking treatment for. Most importantly, there is also a risk that your tailored treatment may cause further aggravation of pain or injury, or may aggravate previously existing conditions.

Please note that due to the risk of further injury with physical therapy techniques, providing a good medical history will help mitigate this risk, especially related to previous injuries. By signing below, you acknowledge that failure to detail all past injuries can result in unfavorable results and risk of further injury.

It is your right to decline any portion of your treatment at any time or during your treatment session.

By signing below, I acknowledge that my treatment program has been explained by Releaseology, LLC and Sara Becker. I also acknowledge that the procedures being performed are individual modalities in order to address my symptoms but should not replace advice or assessment by a medical doctor or a full and formal physical therapy treatment plan. I understand the risks associated by seeking treatment by Releaseology, LLC and I wish to proceed.

*List any medical conditions that may affect your session today (consider blood pressure, fractures, etc). Type none or N/A if not applicable

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