Consent Form

1. PURPOSE OF SCREEN

This session is a brief injury and/or movement screening to identify mobility restrictions, movement limitations, or areas of discomfort.

This is not a full physical therapy evaluation, diagnosis, or treatment session.

2. NATURE OF ACTIVITIES

The screen may include:

• Movement assessments (squat, lunge, overhead motion, etc.)

• Light mobility testing

• Basic strength or stability checks

• Brief corrective exercise suggestions

These activities are low risk, but may involve mild physical exertion.

3. NO MEDICAL DIAGNOSIS OR TREATMENT

I understand that:

• No medical diagnosis will be provided

• This does not establish an ongoing provider-patient relationship

• I may be referred for a full evaluation or medical care if needed

4. ASSUMPTION OF RISK

I understand participation may involve risks including:

• Muscle soreness

• Aggravation of existing symptoms

• Minor strain or discomfort

I voluntarily choose to participate and accept all associated risks.

5. RESPONSIBILITY TO DISCLOSE

I agree to inform the provider of:

• Current injuries, pain, or medical conditions

• Any limitations that may affect participation

• Any discomfort during the session

6. VOLUNTARY PARTICIPATION

I understand:

• Participation is voluntary

• I may stop at any time

7. RELEASE OF LIABILITY

I release and discharge Reach Physical Therapy and Performance, its owner(s), and staff from any liability for injuries or damages resulting from participation, except in cases of gross negligence.

8. MINOR CONSENT (REQUIRED IF UNDER 18)

If the participant is under 18 years of age:

I am the parent or legal guardian of the participant listed above. I consent to their participation in this injury and mobility screen and agree to all terms outlined in this document on their behalf.