Here at Anchored Seat, you, the rider, are at the focus of all that I do. Whether it’s providing unmounted rider fitness assessments, or conducting an in-person clinic, I want to be sure we are on the same page about the assumed risks and liabilities with working on any kind of wellness program – with or without your horse.
When you check the “Consent” button for any service or freebie that I offer, this is what you are agreeing to:
Consent, Release, & Waiver of Liability Agreement
I understand, agree, and consent to receive and participate in wellness services provided by Anchored Seat Physical Therapy Wellness, PLLC, Audrey Paslow, Justin Paslow, and their managers, members, employees, interns, associated riding instructors, associated horse trainers, contractors, volunteers, sponsors, agents, representatives, affiliates, predecessors, successors, and assigns (the Practice refers collectively to the words in italics) to me or to the person whose name is listed below. I represent and agree that I am legally responsible for the person named below. I represent and agree that I am the parent or legal guardian or healthcare agent of the person named below or that I have obtained the required permission and authorization from the parent or legal guardian or healthcare agent of the person named below to execute this agreement on their behalf.
I understand and agree that the Practice performs wellness services. I understand and agree that my wellness sessions with the Practice are not a substitute for medical care, diagnosis or treatment from a physician. If I have been diagnosed with any medical conditions for which the treatment lies outside of the scope of wellness services, I understand and agree that I should see a physician and under no circumstances should I forego any medical treatment recommended by a physician.
I understand and agree that wellness services involve the use of equipment, machines, physical exertion, movement, stretching, and other maneuvers in order to follow a plan to reach goals agreed upon by and for myself or by myself on behalf of the person named below. I agree to these goals in consultation with the Practice. The Practice shall determine what services will be provided through a client assessment which will be conducted during the initial session. I also understand and agree that changes to plans to reach goals may occur and will be determined through further assessment in subsequent sessions.
I understand and agree that the Practice will do its best to ensure no harm comes to any client during the provision of any wellness services. I further understand and agree that wellness services may result in unforeseen accidents or injury or even death. I agree to notify the Practice immediately if anything happens that is painful or feels unusual.
I understand and agree that there are certain wellness services that are inappropriate for women who are pregnant and that it is my responsibility to immediately tell the Practice if I am or become pregnant, so that proper precautions can be taken.
I understand and agree that there are certain wellness services that are inappropriate for anyone who has a pacemaker. I understand and agree that it is my responsibility to immediately tell the Practice if my cardiac condition changes, including installation of a pacemaker so that proper precautions can be taken.
I warrant and represent that I DO NOT have a pacemaker. __________ (Initial here.)
I warrant and represent that I DO have a pacemaker. __________ (Initial here.)
I understand and agree that I have provided all necessary medical, psychological, and physical information that is known to me at the time of signing this document. I understand and agree it is my responsibility to update the Practice in writing of any changes to my medical, psychological, or physical condition. If I do not provide accurate information or fail in writing to update the Practice of any changes, I understand and agree to release and hold the Practice harmless from any liability for any injuries, damages, or claims including those made for negligence, and for attorneys’ fees.
I understand and agree that if a physician’s permission is required by the Practice before I start participating in wellness services, that I am fully responsible for obtaining such permission in writing and presenting it to the Practice prior to the start of participating in wellness services.
I understand and agree that the Practice will keep all communications and records confidential to the extent legally permissible unless I consent in writing to share this information with others. I understand and agree that participating in wellness services provided by does not provide me with HIPAA privacy protections.
I understand and agree that the Practice has not made any warranties, assurances, or guarantees to me. I freely consent and agree to receive wellness services from the Practice. I understand and agree that while the Practice may make certain recommendations or provide information to me during sessions and at other times in the course of me participating in wellness services, that it is entirely my own decision whether or not to accept and follow these recommendations or how to apply the information. I agree that I have read and understood the information provided in this Consent Form, as well as all materials provided to me. I have asked any and all questions that I may have about materials, the sessions, and the course of my care, and that these questions have been answered to my full satisfaction. I agree that I will continue to ask any questions I might have about the sessions, other aspects of my care, or information provided to me until those questions are answered to my satisfaction.
I understand and agree to release and hold the Practice harmless from any liability for any injuries, damages, and claims, including those made for negligence, and for attorneys’ fees, which may arise as a result of my participation in wellness services. I understand and agree that these injuries, damages, and claims include but are not limited to ones that are unforeseen; are the consequences of any decisions I may make, any actions I may take, or choose not to take; and following any recommendation, instructions, or actions made by the Practice, including those made negligently.
I understand and agree that the Practice has a 24-hour cancellation policy and I will be charged a cancellation fee equal to the entire cost of a session for a missed appointment if my cancellation notice is not received by the Practice more than 24 hours in advance of my appointment. I understand and agree that I may reschedule my appointment, without fee, by providing notice to the Practice at least 24 hours in advance of the appointment. For appointments scheduled on Mondays, I understand and agree that my notice of any cancellation or rescheduling must be received by the Practice on the Friday before the appointment.
I understand and agree that payment is required at or before the time of service and that the Practice will accept prepayments for future service.
If any provision of this Consent, Release and Waiver Agreement is found invalid or unenforceable pursuant to judicial decision, the remainder of this Agreement shall remain valid and enforceable according to its terms to the fullest extent of the law.
I represent that I am of sound mind and am legally competent to understand and complete this agreement. I understand and agree that I am freely executing this Consent, Release and Waiver Agreement without coercion.
___________________________ ___________________________
(Printed Name) (Date)
_______________________________
(Signature)