Thank You for Your Premium Blueprint Purchase

1. CONSENT FOR TREATMENT: I consent to and authorize my physical therapist, occupational therapist and other healthcare professionals and assistants who may be involved in my care, to provide care and treatment prescribed by and/or considered necessary or advisable by my physician(s)/health care provider(s). I acknowledge that no guarantees have been made to me about the results of treatment.

 2. RESPONSIBILITY FOR PAYMENT: All payments are due at the time of service. I acknowledge that in consideration of the services provided to me by The Bodyfix Blueprint, LLC. I am financially responsible for payment of my When you provide a check as payment, you authorize us to use the information from your check to process a one-time Electronic Funds Transfer (EFT/ACH) or a draft drawn from your account, or to process the payment as a check transaction. When we use information from your check to make an EFT, funds may be withdrawn from your account as soon as the same day and you will not receive your check back from your financial institution. Please note that refusal to sign this form does not change responsibility for payment in any way.

3. ACCESS TO AND RELEASE OF HEALTH INFORMATION: I understand that The Bodyfix Blueprint, LLC , may document medical and other information related to my treatment in electronic and other forms and that such information will be used in the course of my treatment, for payment purposes and to support those who are caring for me. I authorize my clinician(s) and The Bodyfix Blueprint, LLC , administrative staff to contact other healthcare professionals that may have information related to my prior and current health conditions and treatment. I acknowledge that I have received The Bodyfix Blueprint, LLC , Notice of Privacy Practices and that it outlines how my health information will be used and disclosed and how I may gain access to and control my health information.

4. HIPAA CONSENTS: In compliance with HIPAA regulations, I consent to the following individuals receiving verbal information regarding the billing of my account:

I also authorize the release of appointment information left in a voice-mail, answering machine or text message and understand that there is some level of privacy risk associated with these forms of communication.

5. CONSENT FOR EMERGENCY CONTACT INFORMATION Person to contact in case of an emergency:

By my electronic signature below, I certify that I have read, understand, and fully agree to each of the statements in this document and sign below freely and voluntarily.

I agree that entering my name above is the legal equivalent of my handwritten signature and I consent to be legally bound to this agreement.

The Bodyfix Blueprint, LLC , complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

In agreeing to receive care provided by The Bodyfix Blueprint, LLC, P.O. Box 229272 Glenwood, FL 32722, I agree as follows:

I fully understand and acknowledge that (a) the activities in which I will engage as part of the treatment provided by The Bodyfix Blueprint, LLC  and the equipment I may use as a part of that treatment have inherent risks, dangers, and hazards and such exists in my use of any equipment and my participation in these activities; (b) my participation in such activities and/or use of such equipment may result in injury or illness including, but not limited to, bodily injury, disease, soreness, strains, numbness, tingling, muscle tears, fractures, partial and/or total paralysis, death or other ailments that, could cause serious disability; (c) I hereby assume all risks and dangers and all responsibility for any losses and/or damages whether caused in whole or in part by the negligence or the conduct of the representatives or employees of The Bodyfix Blueprint, LLC  or by any other person; (d) I know that I have the right to choose what treatment I do or do not receive, in addition to withdrawing from treatment at any time; (e) I recognize that my participation in the activity covered hereby is conditioned upon my signing and returning this waiver and release.

I, on behalf of myself, my personal representatives and my heirs, hereby voluntarily agree to release, waive, discharge, hold harmless, defend, and indemnify The Bodyfix Blueprint, LLC  and its 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 that I may have presently or in the future for the negligent acts or other conduct by the representatives or employees of The Bodyfix Blueprint, LLC.  

I understand that I may show this INFORMED CONSENT and WAIVER & RELEASE OF LIABILITY to, and consult with, my own independent legal counsel before signing.

Consent : I consent to and authorize The Bodyfix Blueprint, LLC  (including students in training) 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. IT IS MY INTENTION TO EXEMPT THE BODYFIX BLUEPRINT, LLC  FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH BY ANY CAUSE.

By my electronic signature below, I certify that I have read, understand, and fully agree to each of the statements in this document and sign below freely and voluntarily.

I agree that entering my name above is the legal equivalent of my handwritten signature and I consent to be legally bound to this agreement.