First Name *

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What equipment do you have access to? *

I understand that this is not skilled physical therapy services. It is wellness coaching. *

I understand.

Medical Disclaimer: Our website, services and wellness programs do not provide medical advice. The information, including but not limited to, text, graphics, images, videos, and other material contained in the website and services of wellness programs are for informational purposes only. None of the above material is intended to be a substitute for professional medical advice, diagnosis, or treatment. 40:31 Physical Therapy and Fitness, PLLC services, programs, practitioners, coaches and associates are not diagnosing, treating, curing, mitigating or preventing any type of disease, symptom or medical condition. Always seek advice of a physician or qualified health care provider with your specific questions you may have re: a medical condition or treatment before undertaking a new health care regimen; and never disregard professional medical advice or delay in seeking it because of information in this website, services, wellness programs or other material obtained through 40:31 Physical Therapy and Fitness, PLLC. Waiver and Release of Liability: By my execution of this Agreement I hereby waive any claims or rights that I may have hereafter against 40:31 Physical Therapy and Fitness, PLLC and their respective owner, practitioners and staff (known here forth as releasees) and agree to release and hold these stated releasees absolutely harmless from any and all claims, demands, inquires (including death), damages, losses, liabilities, actions, suits or causes of action to persons or property, present and future arising instruction conducted inside or outside the facilities, whether caused by the negligence of the releasees, except as to such claims which may arise from the gross negligence or willful misconduct of the releasees. I acknowledge that I have carefully read this Waiver and Release of Liability and fully understand it is a release of liability with consent to the Terms and Conditions. Consent: I consent to health and wellness, functional wellness, and related services (not limited to, but can also include: fitness interventions, healthy habit suggestions, dietary supplement suggestions and/or essential oil suggestions or application techniques) as falling within the appropriate guidelines with 40:31 Physical Therapy and Fitness, PLLC and associates. In doing so, I understand, acknowledge, and affirm that such services are considered necessary and within guidelines established by myself and treating health professional provider(s). Please note that services are provided under the known acknowledgment that a primary medical practitioner is in place and that the rendered services are not meant to be a substitute or replace supervising medial advice and/or dietitian or nutritionist's advice. Rather, this is complementary health and wellness care and that the undersigned acknowledges to participate in these services willingly and without a 3rd party primary directive. Furthermore, it is not the intent of these, or related adjunct services, to diagnose, treat, cure or prevent disease or symptoms; in addition, urgent and/or emergency health concerns need to be directed to the appropriate medical/health practitioner/facility. Rather, 40:31 Physical Therapy and Fitness, PLLC are for the facilitation of optimizing wellness. Assumption of Risk: I understand that engaging in health and wellness services, exercise and/or functional medicine/wellness recommendations, dietary supplement suggestions, health progression, essential oil application techniques and/or advice and/or other potential interventions includes an inherent risk of minor or major life-threatening injury to persons and property, and death, including, but not limited to injury arising from or relating to your participation in any supervised or unsupervised above services conducted in or outside of 40:31 Physical Therapy and Fitness, PLLC. I hereby expressly agree to assume full responsibility for all bodily injury, death, property damage, and theft or loss of personal property, that might result from my use of 40:31 Physical Therapy and Fitness, PLLC services, equipment, programs and personal instruction, no matter what causes such injury, damage, or loss, including the active or passive negligence of 40:31 Physical Therapy and Fitness, PLLC owner, practitioner(s) and /or associated staff. *

I HAVE READ THE ABOVE WARNING, WAIVER, RELEASE, AND ASSUMPTION OF RISK. I FULLY UNDERSTAND ITS CONTENTS, AND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT. I HEARBY SIGN IT VOLUNTARILY WITHOUT ANY INDUCEMENT, ASSURANCE, OR GUARANTEE BEING MADE TO ME AND INTEND MY SIGNATURE TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY.

I grant permission to 40:31 Physical Therapy and Fitness, PLLC and its agents or employees, to use photographs taken of me or my minor child/children in classes or events of 40:31 Physical Therapy and Fitness, PLLC for use in publications such as brochures, newsletters, and magazines, and to use the photographs on display boards, and to use such photographs in electronic versions of the same publications or on 40:31 Physical Therapy and Fitness, PLLC web sites or other electronic form or media, and to offer them for use or distribution in other non-company publications, electronic or otherwise, without notifying me. I hereby waive any right to inspect or approve the finished photographs or printed or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the photograph. I hereby agree to release, defend, and hold harmless 40:31 Physical Therapy and Fitness, PLLC and its agents or employees, including any firm publishing and/or distributing the finished product in whole or in part, whether on paper or via electronic media, from and against any claims, damages or liability arising from or related to the use of the photographs, including but not limited to any misuse, distortion, blurring, alteration, optical illusion or use in composite form, either intentionally or otherwise, that may occur or be produced in taking, processing, reduction or production of the finished product, its publication or distribution. *

I have read and understand the above.

I have thoroughly read and agree with the above information. (Signature of participant below) *

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Wellness Program - Fitness ONLY

Subscription

$99

Wellness Program - Fitness & Nutrition

Subscription

$149

Women's Health Wellness Program

Subscription

$215

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