CLIENT AGREEMENT AND WAIVER FORM

In consideration of my availment of the physiotherapy services, I understand that prior to availment of any service, I have read and fully understand the assumed risks for participation and Waiver of Liability specified herein:

Voluntary Participation and Assumption of Risks

I fully understand that I am engaging in physical therapy, that includes exercises, use of exercise equipment, physiotherapy modalities, facilities, training and instructions of a professional physiotherapist which are for therapeutic purposes but may cause unintended complications. I hereby agree that I am voluntarily participating in physiotherapy, the use of the gym/club/locator's facilities, and instruction of a physiotherapist.

I understand that implementation of the programs are voluntary and that a physiotherapist will develop and guide me through my exercise program  to best of his/her ability. I will be required to undergo an assessment in person, via call, or virtual assessment.

I understand that I  will complete the Client Information form accurately and completely, including disclosure of any prescribed medications I am taking, any exercise or diet limitations I am aware of and had been informed by my physician.

I understand that the physiotherapist will review any medical referral or medical diagnostics but that a physiotherapist is not a physician and cannot replace the advice, review and expertise of a physician.

I understand that I am required to get a medical referral for my physiotherapy session but I voluntarily commit to an initial session for an immediate therapeutic care for my needs. 

I realize that participation in the program including but not limited to exercising, use of exercise equipment and strenuous exertion (strength  training) all of which increase heart rate and body temperature.

I understand and voluntarily participate to procedures that I may have to expose some of my body parts that needs to be inspected, manually assessed and treated, and other related regions that the Physiotherapist will ask. I understand and voluntarily commit to these participations and that the physiotherapist may use manual force, with or without physiotherapy modalities as necessary, for therapeutic purposes. I voluntarily commit to some procedures that may feel uncomfortable, require punctures in skin, bruising, bleeding, and muscle soreness, and I understand that these are of therapeutic purposes.

I understand that participating in the physical therapy exercises and procedures comes with inherent risks including but not limited to (1) serious neck and spinal  injuries resulting in complete or partial paralysis, heart attack, stroke or even death (2) injuries could occur to bones, joints or muscles (3) Slips,  falls, and unintended loss of balance could result in muscular, neurological, orthopedic or other bodily injury (4) Illness, including exposure to and  infection with viruses or bacteria. I understand that part of the risk involved in undertaking any activity or program is relative to my own state of  fitness or health (physical, mental, or emotional) and to the awareness, care and skill which I conduct myself in that activities or programs. Knowing the material risks and appreciating, knowing and reasonably anticipating that other injuries are a possibility, I hereby expressly assume  all of the delineated risks of injury, all other possible risk of injury, and even risk of possible death, which could occur by reason of my participation.

I also understand that I am accountable for my personal belongings and further agree to release the physiotherapist, the gym/facility the clinic is located, its administration, from any liability for any loss or theft of property.

I understand and agree that the physiotherapist and the facility may reschedule, refuse service or entry, ban, and may revoke remaining sessions, if I have been proven to pose health and safety risks to any of the parties; have been proven uncapable or risky to participate in the physiotherapy sessions; have been proven and deemed unruly, disruptive, and had done immoral character or behavior towards the physiotherapist and the facility.

I also assume responsibility for proper use of equipment and properties of the clinic and facility, once endorsed to me for physiotherapy participation on its intended purpose. Any defects or damage to  properties I incurred while I am using it for physiotherapy participation or due to negligence, will be charged accordingly to my account, payable in terms agreed upon by involved parties.

I do hereby waive, release and forever discharge the physiotherapist, the gym/facility the clinic is located, its administration, from any and all responsibilities or liability for any present and future  injuries or damages resulting or arising from my participation in any activities including but not limited to exercise, self directed physical therapy home exercise program, complications secondary to physical therapy procedures, or use of the  equipment including any injuries and damages caused by the negligent act or omission of any of those persons or entities mentioned above.

I understand that being a client of the physiotherapy service does not make me a member of the gym or facility where the physiotherapy service was conducted. I am solely a client of the physiotherapist in charge and I have limited access to locator's facilities, and access is solely of physiotherapy purpose. Any other activities in the facility done outside physiotherapy will be on my account and subject to any facility charges, as necessitated by the location's administration.

Obligation to Declare Physical Disabilities, Impairments or Ailments

I hereby warrant, represent and agree that I will be responsible for any of my physical disability, impairment or ailment, as I engage in any physical therapy exercises and  activities that maybe be detrimental or inimical to health, safety, comfort, physical condition or that of others. I agree to consult my physician before  undertaking a physical therapy program. During the program if my medications, condition, or medical limitations should change, I will notify the physiotherapist. I understand that it is recommended that I have a yearly physical or more frequent physical examination and consultation with my physician as to physical activity and diet so I am aware of what is appropriate for me. I acknowledge that I have either had a physical exam and have been given my physician’s permission to participate or I have decided to participate without approval of my physician. I understand that I have the complete right to stop or decrease exercise at any time during a session and that it is my obligation to inform the physiotherapist of any symptoms such as fatigue, shortness of breath or chest discomfort.

A. Compliance to Rules and Regulations

I fully agree to follow all rules and regulations declared by the physiotherapist, clinic and the facility. The physiotherapist, clinic and the facility reserves the right to change or modify these rules and regulations in the future without prior notification. The physiotherapist, clinic and the facility reserves the right to revoke Agreement if I will fully fail or refuse to abide by such rules and regulations. 

1. Please make sure to have your appointments booked prior to your visit. Upon arrival, our staff shall check and confirm your booked slot prior to allowing your entry to the gym or physical therapy clinic.

2. Please be on an attire and footwear that will allow you to move freely, and expose body parts to be treated. 

3. Please wear mask as necessary if you have cough, or any respiratory problems. Please inform your physiotherapist in advance so they can make adjustments as necessary, or rescheduling until you are deemed safe for physiotherapy participation. 

4. All gym users must bring their own hydration and towels.

5. Removals of facemasks are allowed during high intensity workouts. Bringing of extra face mask is encouraged.

6. Allotted time slot for usage of facility and availment of services with cleaning times in between shall be observed.

7. Everyone is encouraged to practice good personal hygiene.

8. Please inform the physiotherapist and the facility in advance if you will be bringing any company/chaperone. They maybe asked to be in a waiting area as you participate in the physical therapy session. If you will be requiring someone to observe your physical therapy session, please inform in advance, and will be subject for approval from the physiotherapist.

9. If a property or equipment is damaged due to the fault or willful negligence, the expenses for repairs of the said property shall be for the account of the customer. An incident report and promissory note shall be duly accomplished.

B. VALIDITY and USE POLICY

Any purchased single session should be consumed within 14 days from date of purchase. Any Package should be activated within two (2) weeks from day of purchase, and should be scheduled and consumed within 30 days from date of purchase. Upon purchase, the validity period of the membership package shall start. Session and packages is consumable within validity period only.

C. TRANSFER POLICY

Members are allowed to transfer their services but must comply with the specific conditions and procedures. Clients who have requested Freezing of sessions can no longer transfer their sessions. Transfer of remaining sessions/ contents of package is not allowed to existing clients three months prior to date of transfer. A session/package is considered consumed if any professional time had been consumed, procedure performed, advise, consultation, programming has been given out by the physiotherapist.

1. Viable Session and packages can be transferred but only once.

a. By clients that has no pending account balance and/or recurring/future payment transactions thereafter.

b. To individuals that will assume pending account balance and/or recurring/future payment transactions thereafter.

c. If a package has only consumed 1 session

d. To an individual that is a not yet a client. Transfer to a current or previous client within three months past time is not allowed.

2. A request, supporting documents must be submitted and subject to the approval of physiotherapist and facility. 

D. PHYSIOTHERAPY AT CLINICS AND AFFILIATE FACILITIES

Physiotherapy is conducted for a fee at clinics and affiliate facilities. They are provided by and recognized by the clinic and the facility. Physical therapists and procedures performed that are not honored and related to the clinic will not be recognized and are prohibited from intervening in the procedures and programming, misrepresenting, or any other related actions, in behalf of the clinic. The physiotherapists of the clinic will not be liable to any complications or injuries due to the interventions of non-qualified physiotherapists. Physiotherapists honored by the clinic, are maintaining certification through a nationally recognized organization and have met specific academic requirements essential for quality physiotherapy session.

An individual may be seen as intervening and misrepresenting if he/she is:

 Receiving payment in behalf of the clinic for an exercise or programming

 Designing a program or workout in behalf of the clinic

 Providing exercise, procedures, training techniques thru verbal, virtual, and manual coaching

E. FREEZING POLICY

Freezing of the validity of certain services are allowed if reason is found to be valid such as travel or injuries. The physiotgerapists reserves the  right to refuse freezing on case to case basis, and if timely request is not provided. Should this occur, Member must express desire to validity freezing at least 7 days from desired date and pay the equivalent amount for the Freezing period requested, as applicable

For Packages and Sessions

 Free for 2 weeks Freezing

 Freezing up to maximum of 4 months for PHP500/month Fee

F. REFUND POLICY

No refund shall be given for any service availed. Should client not be satisfied with a certain package or service Upgrade or change of 

package to the equivalent amount may be allowed. For upgraded services, excess amount must be paid. For downgraded services, no refund 

shall be given for excess amount

G. CANCELLATION POLICY

- Cancellation of package and sessions is allowed, however, no refund shall be provided for any remaining unused sessions. 

- Cancellation of Appointments 

 Must be done at least 48 hours before the session otherwise session shall be considered used and/or deducted/debited from packaged sessions availed, as applicable. 

 Session will not be deducted if reason is found to be valid. Approval shall be on a case-to-case basis.

H. RESCHEDULING OF SESSION POLICY

- Rescheduling is highly discouraged, but should be permitted a week after the original schedule, or on case to case basis.

- Rescheduling of a session is only allowed ONCE. 

The Physiotherapist  reserves the right to change the policies with or without prior notice to clients.

I declare that I have read, understand and agree to the contents of this Agreement Form in its entirety. I understand that th e Assumption of Risk 

and Waiver of Liability are intended to be as broad and inclusive as permitted by the Republic of the Philippines and agree that if any portion is 

held invalid, the remainder will continue in full force and effect.

(Sign on Client Information Sheet)

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