Client Agreement and Release

FIRST OF THREE FORMS:
Below is the first of three brief forms. Please complete and submit the form, then you will be transferred to the second form.

First Name*

Last Name*

Minor Name (if applicable)

Date of Birth

Street Address*

City*

State*

Zip Code*

Phone Number*

Email*

In consideration of receiving certain services from BTI Sports and Wellness, LLC (“BTI”), I enter into this Agreement knowingly, intelligently and voluntarily, and agree on the following date as follows:

Date*

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1.
Client Definition. I understand and agree that I am signing this Agreement on my own behalf and that I am an adult individual, aged eighteen (18) years or older. In the event that a minor child is named above, I warrant and represent that I am the parent or legal guardian of the subject minor child (hereinafter the named minor child shall be referred to as my “minor child”), that I agree for BTI to provide the Services, as defined below, to my minor child, and that I am executing this Agreement on behalf of my minor child, and individually, jointly, and severally on behalf of myself. In the event that my minor child shall receive the Services, I acknowledge and agree that sufficient consideration exists such that my minor child shall be considered a third-party beneficiary of this Agreement.

Initial Client Definition*

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2.
Consent for Treatment. I understand that I am requesting and agreeing that BTI will provide certain services, including physical therapy services in the nature and frequency described above (the “Services”) to me and/or the minor child. I acknowledge and represent that I and/or my minor child do not have any physical, emotional, or medical condition that might create risks for me and/or my minor child, or others to receive the Services. I have consulted with any medical providers that I deemed appropriate prior to commencing the Services and entering into this Agreement and certify, warrant and represent that I and/or my minor child are able to receive the Services. I understand, and accept that BTI, its employees, members, agents and representatives are health care professionals in the area of physical therapy, and that their specific expertise may not be in the area of identifying medical emergencies, and that they are not obligated to obtain or provide medical care at any time, other than the provision of the Services, which they shall provide in their reasonable judgment. In the event that BTI, its employees, members, agents, or representatives choose to obtain emergency medical care for me and/or my minor child, I expressly consent to the same and agree to be responsible for any and all costs involved therein.

Initial Consent for Treatment*

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3.
Assumption of Risk. I acknowledge, understand, and accept that in the course of receiving the Services I and/or my minor child will be exposed to risks, including, without limitation: slips, falls, collisions with fixed objects, equipment failure or malfunction, defect or risks associated with BTI’s facilities, and the acts or omissions of myself, my minor child, BTI, its employees, members, agents, or representatives, or third parties. I acknowledge, understand, and accept that the receipt of the Services may include other risks which are not listed here, and that any such risks are inherent to the Services and cannot be eliminated without destroying the inherent nature of the Services. I acknowledge, understand and agree that the risks may result in any and all manner of harm, trauma, and/or injury, including but not limited to broken bones, sprains, abrasions, emotional harm, mental impairment, serious injury, death, and/or loss or damage to property, including to personal property. I, on my own behalf and/or on behalf of my minor child, acknowledge, understand, and freely assume all such risks, inherent or otherwise, whether listed here or not. In the event that my minor child shall receive the Services, I have discussed the risks with the minor child, and they desire to proceed. I, on my own behalf, and on behalf of my minor child, agree to abide by any rules, regulations, or directions which BTI, its employees, members, agents, or representatives issue at any time.

Initial Assumption of Risk*

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4.
Disclaimer of Guarantee or Warranty. I acknowledge, understand and agree that the progress and results of the Services depends on a number of factors, including factors that BTI cannot control such as my conduct and/or the conduct of my minor child, both now and in the future, without limitation. As a result, I understand that BTI does not warrant or guarantee or make any representations about the progress or results of the Services, whether express or implied and that BTI disclaims the same.

Initial Disclaimer of Guarantee or Warranty*

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5.
Release and Indemnification. On behalf of myself and my minor child, I hereby release and agree to indemnify, defend, and hold BTI, its employees, members, independent contractors, agents, representatives, successors, assigns, subsidiaries and/or affiliates harmless from and against any and all claims, causes of action, demands, suits, proceedings, liabilities, losses, judgments, costs or expenses, including, without limitation, attorneys’ fees, of any kind, which arise from or relate, in any way, to the Services, including but not limited to those which arise from or relate to the presence of me, my minor child, or any family members or guests thereof on BTI’s premises, the use of BTI’s equipment, facilities, or services, or otherwise. This paragraph shall survive the termination of this Agreement and the provision of the Services.

Initial Release and Indemnification*

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6.
Email and Cell Phone Confidentiality. BTI is committed to keeping your email address and cell phone number confidential. BTI will only use your email address and or cell phone number to provide timely information about BTI and/or its affiliates for treatment/payment/healthcare operations purposes. I am expressly consenting to receive text and or email and or phone call communications. I may opt out at any time.

Initial Email and Cell Phone Confidentiality*

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Name (Online Signature)*

Date2*

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