CCR FX Physical Therapy Event Consent 1.22

Name (First)*

Name (Last)*

M.I.

Address

Street Address

Street Address Line 2

City, State

Zip Code

Telephone Number*

Email*

example@example.com

Insurance Provider

Member ID

DOB

Consent to Medical and Therapeutic Services*

I consent to the procedures and screenings, which may be performed during the duration of this outpatient treatment, including emergency treatment. I understand that medical, nursing, and other health care personnel in training who, unless requested otherwise, may be present during patient care or may provide care as a part of their education. I also understand that the rehabilitation process, by its very nature, involves certain inherent unavoidable risks, including falls, and other similar injuries, and that the only alternative to entirely avoid these risks would be to forego rehabilitation altogether.

Photograph/Video Consent Release

I irrevocably grant FX Physical Therapy, its assigns, licensees, affiliates, and successors the absolute and irrevocable right and unrestricted permission to use my likeness, image, voice and name in all forms and media including composite or modified representations for all purposes, including, but not limited to, advertising, trade, or any commercial purpose throughout the world and in perpetuity. I waive the right to inspect or approve versions of such material for publication or the written copy that may be used in connection with the images. I release FX Physical Therapy and its assigns, licensees, affiliates, and successors from any claims that may arise regarding the use of such material, including, but not limited to, any claims of defamation, invasion of privacy, or infringement of moral rights, rights of publicity, misappropriation, or copyright. I acknowledge that I will not receive any compensation for the use of such materials.I do not grant FX Physical Therapy, its assigns, licensees, affiliates, and successors the absolute and irrevocable right and unrestricted permission to use my likeness, image, voice and name in all forms and media including composite or modified representations for all purposes, including, but not limited to, advertising, trade, or any commercial purpose throughout the world and in perpetuity. I waive the right to inspect or approve versions of such material for publication or the written copy that may be used in connection with the images. I release FX Physical Therapy and its assigns, licensees, affiliates, and successors from any claims that may arise regarding the use of such material, including, but not limited to, any claims of defamation, invasion of privacy, or infringement of moral rights, rights of publicity, misappropriation, or copyright. I acknowledge that I will not receive any compensation for the use of such materials.

Patient Name Printed

Patient Signature

Date

Parent or Legal Guardian Signature

Date

Under 18 Parent or Legal Guardian Name