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Individual Injury Screening and Assessment
Consent & Liability Acknowledgment

Please carefully read the following information. 

Thank you for attending our individual injury screening/assessment session designed to identify the cause of your pain/injury and help to provide you some guidance on the best way to manage this issue you’re having going forward. We hope to help enhance your musculoskeletal health and performance. Following the injury assessment, we will provide you with a few simple suggestions exercises and/or stretches) to work on at home to reduce the risk of injury and to enhance performance, strength, and stability.

The purpose of this screen is not necessarily to diagnose or treat, but rather give you our best advice on how to manage your pain/injury based on our education, training, and experience as medical professionals. While the screen will be performed by trained individuals, participation in the injury screen does carry with it a risk of injury that cannot be eliminated regardless of the care taken to avoid such injuries and the undersigned individual shall assume all risk by participating in the injury assessment.

By signing below, and in consideration for the aforementioned assessment, I do waive and forever release any and all rights and claims for any damages and liabilities of any kind arising out of my participation in this screening process, against all persons, entities, and agencies involved with performing the injury assessments, including but not limited to: the facility at which this assessment is taking place, Movement Driven Performance Physiotherapy PLCC, and any other related individuals or entities.

I understand that this injury screening is not intended to diagnose or treat any injuries, but to identify glaring mobility or strength deficits and assist with optimizing your movement. I also understand that my participation in this in injury screening is not a guarantee of reducing or curing my injury/pain. The results will not be shared with any individuals or entities except as outlined herein and will only be used for informational purposes including tracking of injuries and/or trends.

I also agree to being contacted by Movement Driven Performance Physiotherapy PLCC in the future. We will not share your personal information here onto per Movement Driven Performance Physiotherapy PLCC Privacy Policy. I have carefully read this waiver of liability and understand that I am giving up legal rights, including my right to sue. I acknowledge that I am signing this waiver freely and voluntarily and intend by my signature to be a complete and unconditional release of all liability to the extent allowed by law.


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