I am aware that Change in Motion, through its employees or agents, will provide consultation services to me in my home and in outdoor spaces. I understand that these services do not include skilled occupational therapy treatment and are not intended to treat any specific medical condition or conditions. I understand that these consultation services are not considered healthcare services and therefore will not be paid for or reimbursed by any health insurance or other healthcare payment sources. I understand that these consultation services may carry the following risks: physical pain and discomfort, physical injury and stress, falls and property damage. I understand these risks are not exhaustive and that there may be other, more remote risks and consequences. I have been advised that a more detailed explanation will be given to me if I so desire, and I do not want further explanation. I have received no guarantees from anyone of the results that may be obtained. I hereby consent to receiving these services.
Change in Motion may document information related to these services in electronic and other forms. Change in Motion will not divulge any confidential information (information not generally known) without permission, unless permitted or required by law.
In consideration of being allowed to receive the services described above, I do hereby waive, release and forever discharge Change in Motion LLC, and its affiliates, officers, employees, agents, representatives and all others acting on its behalf, their successors and assigns (the “Released Parties”), from any and all claims or causes of action (known or unknown) for any and all injury, illness, damage or loss that may occur to me or my property as a result of my receipt of services, including, but not limited to, my use of any recommended services or devices, whether or not said injury, illness, damage, or loss is caused in whole or in part by the negligence of any of the Released Parties. I intend for the foregoing waiver, release and discharge to be binding upon my heirs, executors, administrators, successors and assigns.
This consent and authorization given to Change in Motion as set forth above will remain in full force and effect until terminated in writing by me or my authorized representative. This termination will not be effective until Change in Motion receives this request in writing.
By my signature below, I hereby certify that I have read, understand, and fully agree to each of the statements in this document; that all of my questions have been answered to my satisfaction; and that I sign below freely and voluntarily.
