STRENGTH AND CONDITIONING PROGRAM INFORMED CONSENT

FINANCIAL POLICIES

I understand that payment for service is due at the time of service. I am responsible for seeking my own reimbursement from my insurance company, FSA or HSA. I am responsible for understanding the requirements of my insurance, including need for referrals, prescriptions, deductibles and copayments and its limitations. For the initial visit, it is $175. For subsequent visits, it is $125. I agree that Peak Physical Therapy, LLC may discuss my treatment with my physician for the purpose of my care only. It is my right to understand the treatment which I am participating in and I can refuse participation at any time. By signing this form, I consent to strength and conditioning training.

PROGRAM OBJECTIVES

Strength and conditioning: I understand that my strength and conditioning program is individually tailored to meet the goals and objectives agreed upon by my Certified Strength and Conditioning Specialist (CSCS) and me.

DESCRIPTION OF THE EXERCISE PROGRAM

I understand that my exercise program will involve participation in a number of types of fitness activities. These activities will vary depending upon the objectives that my CSCS and I establish, but will probably include: 1)aerobic activities; 2) muscular endurance and strength building exercises; 3) other activities selected by my CSCS and agreed upon by me; and 4) selected physical fitness tests.

DESCRIPTION OF POTENTIAL RISKS

I understand that no exercise program is without inherent risks regardless of the care taken by a CSCS and that my personal safety cannot be guaranteed by my CSCS. I realize that when participating in any exercises, particularly those that induce cardiovascular stress, there is a slight chance of serious injury (e.g., heart attack, stroke, or other cardiovascular accidents) or catastrophic incident (e.g., death, paralysis). Likewise, I know that engaging in muscular endurance, strength building, and other fitness activities sometimes results in minor injuries (e.g., bruises, musculoskeletal strains and sprains), less frequent, more serious injuries (e.g., muscle tears, herniated disks, torn rotator cuffs), and rarely, catastrophic injury (e.g., death, paralysis).

DESCRIPTION OF POTENTIAL BENEFITS

I understand that a regular exercise program has been shown to have definite benefits to general health and well-being. I know that some of the benefits can include loss of weight, reduction of body fat, improvement of blood lipids, lowering of blood pressure, improvement of cardiovascular function, reduction in the risk of heart disease, improved strength and muscular endurance, improved posture, improved flexibility and overall improved function.

PARTICIPANT RESPONSIBILITIES

I understand that it is my responsibility to 1) fully disclose any health issues or medications that are relevant to participation in a strenuous exercise program; 2) cease exercise and report promptly any unusual feelings (e.g., chest discomfort, nausea, difficulty breathing, apparent injury) during the exercise program; and 3) clear my participation with my physician.

PARTICIPANT ACKNOWLEDGEMENTS

In agreeing to this exercise program:

· I acknowledge that my participation is completely voluntary

· I understand the potential physical risks involved in the exercise program and believe that the potential benefits outweigh those risks.

· I give consent to certain physical touching that may be necessary to ensure proper technique and body alignment.

· I understand that the achievement of health or fitness goals cannot be guaranteed.

· I have had a voice in planning and approving the activities selected for my exercise program.

· I have been able to ask questions regarding any concerns I might have, and have had those questions answered to my satisfaction.

· I am in good physical condition, have no impairment which might prevent my participation in such activities, and have been advised to consult with a physician prior to beginning this program.

· I have been advised to cease activity immediately if I experience unusual discomfort and feel the need to stop.

I have read and understand the above agreement; I have been able to ask questions regarding any concerns I might have; I have had those questions answered to my satisfaction; and I am freely signing this agreement.

CANCELLATION POLICY

I understand that if I cancel less than 12 hours in advance, or fail to show up for a scheduled appointment, I will be charged a fee of $125.