MEMBERSHIP SERVICES WAIVER

I acknowledge that Physio Strength Physical Therapy, PLLC d/b/a PhysioStrength and Clinton Lee Physical Therapy LLC, its owners, contractors or employees will provide the following performance services: (a) wellness & performance coaching (b) exercise programming review. I also acknowledge that the risks and benefits of these aforementioned services have either been explained to me or that I have read them in written detail; performance services may not have the result that I expect, and I have been informed of other possible avenues of improvement for the goals that I am seeking. I have had ample opportunity and time to discuss my concerns with Dr. Clinton Lee, PT, DPT or other individuals working for Physio Strength Physical Therapy, PLLC & Clinton Lee Physical Therapy LLC, and all my questions have been answered to my satisfaction regarding the wellness services being offered.

The performance coaching, exercise programming review and wellness services mentioned above do not include, and I will not be provided, any of the following: Physical examination, medical evaluation, or testing for: (a) any mechanical, physiological, or developmental impairment; (b) functional limitation related to physical movement and mobility; or (c) disability, or other movement-related health condition; alleviation for any impairment or functional limitation through instruction, design, implementation, or modification of any therapeutic intervention; reduction in my risk of injury, impairment, functional limitation, disability, or promotion of maintenance of fitness, health, or quality of life.

I acknowledge and agree that these aforementioned services may be provided remotely, including by phone, software applications through which digital content may be shared, video conferencing software and/or email. I acknowledge that these aforementioned services are not physical therapy. I acknowledge that receiving these aforementioned services does not constitute the practice of physical therapy or any other service for which a state licensure is required. These deliverable services are based upon its owners’, agents’, or employees’ proficiency in and knowledge of how to help clients set and reach their performance goals. Nothing in this policy is intended to limit the ability of Physio Strength Physical Therapy, PLLC & Clinton Lee Physical Therapy LLC or the employees or contractors that they utilize to employ appropriate and lawful physical therapy techniques that they are educated and licensed to perform.  Additionally, this policy does not extend the scope of practice for any activity, treatment, or consultation for which Physio Strength Physical Therapy, PLLC & Clinton Lee Physical Therapy LLC, its employees or its contractors are unlicensed, unqualified, or not lawfully permitted to provide.

In signing this release, I acknowledge and represent that: 
A.  I have read the foregoing release, understand it, and sign it voluntarily as my own free act and deed; 
B.  No oral representation, statements or inducements, apart from the foregoing written agreement, have been made; 
C.  I am at least eighteen (18) years of age and fully competent; and 
D.  I execute this release for full, adequate and complete consideration fully intending to be bound by same.
E.  I understand it shall stay in effect and on file indefinitely, therefore future waivers need not be signed.