Loading...

STRTTODAY LLC

Strength Training and Recovery Treatment 

INFORMED CONSENT & WAIVER / RELEASE OF LIABILITY

I fully understand and acknowledge that (a) the activities in which I will engage as part of the treatment provided by STRTTODAYand the equipment I may use as part of that treatment have inherent risks, dangers, and hazards and such exists in the 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, sickness, 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 STRTTODAY, or by any other person affiliated with STRTTODAYor present atSTRTTODAY’splace of business; (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 given time; (e) I recognize that my participation in the activity covered hereby is conditioned upon my signing and returning this waiver and release.

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 STRTTODAYto administer recovery treatment and/or performance training under the direction and supervision of the specialist. I understand and am informed that, as in the practice of medicine, recovery treatment 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 specialist/staff about any health problems or allergies I have, as well as medication I am taking. I HAVE READ THE ABOVE WAIVER AND RELEASE AND BY SIGNING IT AGREE. IT IS MY INTENTION TO EXEMPT START FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH BY ANY CAUSE.

PRIVACY POLICY

This policy outlines the way Patient Health Information (PHI) will be used in this office and the patient’s rights concerning those records. You must read and consent to this policy before receiving services. A complete copy of the Health Information Portability and Accountability Act (HIPAA) is available here: http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html

  1. The patient understands and agrees to allow this business to use their PHI for the purpose of treatment, payment, and coordination of care. The patient agrees to allow this office to submit requested PHI to the payor(s) named by the patient for the purpose of payment. This office will limit the release of all PHI to the minimum necessary to receive payment.
  2. The patient has the right to examine and obtain a copy of their health records at any time and request corrections. The patient may request to know what disclosures have been made and submit in writing any further restrictions on the use of their PHI. This business is not obligated to agree to those restrictions.
  3. The patient’s written consent shall remain in effect for as long as the patient receives care at this business, regardless of the passage of time, unless the patient provides written notice to revoke their consent. A revocation of consent will not apply to any prior care or services.
  4. This business is committed to protecting your PHI and meeting HIPAA obligations: staff have been trained in the area of patient record privacy and the privacy official has been designated to enforce those procedures.
  5. Patients have the right to file a formal complaint with our privacy official about any suspected violations.
  6. This business has the right to refuse treatment if the patient does not accept the terms of this policy. 

SOCIAL MEDIA CONSENT/WAIVER

During your treatment we may ask your permission to take photo(s) and/or video(s).

I hereby grant STRTTODAY, the unlimited right and permission to use in perpetuity my photograph video footage, actions, and /or testimonial, either alone or accompanied by other material, in any manner and in any media, throughout the world, at any time, for any and all lawful purposes, including but not limiting to, all promotion, marketing, advertising, and publicizing of STRTTODAY’sservices, or STRTTODAY’sclients’ products or services.

I acknowledge that I shall have no right of approval and no claim of compensation.

I acknowledge that any pictures and/or video recordings taken of me by STRTTODAYor any third party contracted by STRTTODAYto perform such actions are or will by the sole property of STRTTODAY. I acknowledge that I am over the age of 18 and have read, understand, and agree to all terms and conditions presented in this Consent and Release, and that I have the full and exclusive authority to grant the rights granted here under.

PAYMENT POLICY AND FINANCIAL AGREEMENT

We are committed to providing you with the best possible care. STRTTODAYis a cash-based business. As a cash-based business we are able to provide you with the upmost care that is specific to your needs without the constraints of a physician referral or insurance parameters.

The undersigned is aware that STRTTODAYis not responsible for insurance reimbursement and that services provided are not based on reimbursement.

The undersigned is aware that STRTTODAYretains credit card information and is authorized to charge any outstanding balance without prior notification to the patient via phone, call, email, and text alert.

CANCELLATION & NO-SHOW POLICY

At STRTTODAY, we understand that unanticipated events happen. With the intent of effectiveness, fairness, and valuing our specialists’ time, we have the following policies outlined below:

2-Hour advance notice is required when cancelling any appointment, which allows the appointment enough time to be filled.

You will be charged 50% of your scheduled treatment session missed.

No-shows will follow the same protocol.

Arriving to appointment times late will not decrease the amount the session costs or will not be accommodated on the back end of the appointment. The specialist will determine if there is enough time for a full and effective session.


Signature of Participant OR Parent/Guardian if Participant is under age of majority:

Date signed: June 13, 2024



First Patient's/Client's Name

First Name*

Last Name*

Phone*
First Patient's/Client's Date of Birth*
First Patient's/Client's Signature*
Second Patient's/Client's Name

First Name*

Last Name*
Second Patient's/Client's Date of Birth*
Third Patient's/Client's Name

First Name*

Last Name*
Third Patient's/Client's Date of Birth*
Fourth Patient's/Client's Name

First Name*

Last Name*
Fourth Patient's/Client's Date of Birth*
Fifth Patient's/Client's Name

First Name*

Last Name*
Fifth Patient's/Client's Date of Birth*
Sixth Patient's/Client's Name

First Name*

Last Name*
Sixth Patient's/Client's Date of Birth*
Seventh Patient's/Client's Name

First Name*

Last Name*
Seventh Patient's/Client's Date of Birth*
Eighth Patient's/Client's Name

First Name*

Last Name*
Eighth Patient's/Client's Date of Birth*
Ninth Patient's/Client's Name

First Name*

Last Name*
Ninth Patient's/Client's Date of Birth*
Tenth Patient's/Client's Name

First Name*

Last Name*
Tenth Patient's/Client's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Patient's/Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!