Fill and Sign the Waiver Release Agreement Form

Waiver, Release, and Indemnification Agreement for Physical Therapy Treatments This Waiver, Release, and Indemnification Agreement for Physical Therapy Treatments is being entered into this _________________ (date) by ________________________ (Name of Patient) , of ___________________________ ____________________ (street address, city, state, zip code) , referred to herein as Patient , in favor of _________________________ (Name of Physical Therapy Clinic) , a profession corporation a corporation organized and existing under the laws of the state of ________________, with its principal office located at ____________________ _____________________________ (street address, city, state, zip code) , referred to herein as PC ; Whereas, the undersigned Patient desires to use the services of PC; Now, therefore, for and in consideration of using said the services offered by PC , and other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the undersigned Patient does hereby waive and release, indemnify, hold harmless and forever PC, and its agents, employees, officers, directors, affiliates, successors and assigns, of and from any and all claims, demands, debts, contracts, expenses, causes of action, lawsuits, damages and liabilities, of every kind and nature, whether known or unknown, in law or equity, that I ever had or may have, arising from or in any way related to the services being provided to me by PC, provided, however, that this waiver of liability does not apply to any acts of gross negligence, or intentional, willful or wanton misconduct. By this Waiver, Release, and Indemnification Agreement I assume any risk, and take full responsibility and waive any claims of personal injury, death or damage to personal property associated with such services by PC. This Agreement contains the entire agreement between PC and myself, and supersedes any prior written or oral agreements concerning the subject matter of this Agreement. The provisions of this Agreement may not be waived, altered, amended or repealed, in whole or in part, without the prior written consent of PC and myself. The provision of this Agreement will continue in full force and effect even after the termination of the services being provided to me, whether by agreement, by operation of law, or otherwise. I have read, understand and fully agree to the terms of this Agreement . I understand and confirm that by signing this Agreement . I have given up considerable future legal rights. I have signed this Agreement freely, voluntarily, under no duress or threat of duress, without inducement, promise or guarantee being communicated to me. My signature is proof of my intention to execute a complete and unconditional this Waiver, Release, and Indemnification Agreement regarding any and all liability to the full extent of the law. I am 18 year of age or older and mentally competent to enter into this Agreement. WITNESS my signature as of the day and year first above stated. _________________________ (Printed Name of Patient) _________________________ (Signature of Patient) Parent or Guardian must sign if Patient is under 18 years of age. The undersigned, as parent(s) or guardian(s) of the above named Patient agree individually and on behalf of my/our child or ward, to the terms of the above Waiver, Release, and Indemnification Agreement, and shall abide by the terms thereof in place of Patient if he/she is under the age of 18. WITNESS our signature on this the ____ day of ___________, 20____. ______________________________ (Printed Name of Parent or Guardian) ______________________________ (Signature of Parent or Guardian) ______________________________ (Printed Name of Parent or Guardian) ______________________________ (Signature of Parent or Guardian)