Informed Consent to Participate

GOAL: The clinic’s goal is to develop a physical activity in order to improve your overall health. Reaching the goal of optimum health, absent other non-physical activity complicating factors, requires a sincere commitment from you, possible lifestyle changes and a positive attitude.

Client acknowledges and understands that treatments and advice will be made in their best interest using the information provided by them. The class instructor will apply judgment based upon current scientific research and the patient’s unique physical and psychological characteristics.

The clinic instructor is not trained to provide medical diagnoses, and no comment or recommendation should be construed as being a medical diagnosis or medical opinion. Since every human being is unique, the class instructor cannot guarantee any specific result from a recommendation.

HEALTH CONCERNS: If you suffer from a medical or pathological condition, you need to consult with an appropriate healthcare provider. Consulting with the class instructor is not a substitute for being treated by your primary care provider or other appropriate healthcare practitioner. The class instructor is not trained nor licensed to diagnose or treat pathological conditions, illnesses, injuries or diseases.

Client understands that the reaction of the heart, lung, and blood vessel system to exercise cannot always be predicted with accuracy. If symptoms such as fatigue, shortness of breath, chest discomfort or similar occurrences appear, patient should stop exercise and inform their physician. Use of weight lifting equipment, engaging in cardiovascular activity and stretching may lead to musculoskeletal strains, pain and injury if adequate warm-up, cool-down, gradual progression and safety procedures are not followed. Client understands that the class instructor shall not be liable for any damages arising from personal injuries sustained while and during engagement in the prescribed physical activity program. The patient following the prescribed physical activity does so at his/her own risk and assumes full responsibility for any injuries or damages, which may occur.

If you are under the care of a healthcare provider, it is important that you contact said healthcare provider and alert them to the fact that you will be embarking on a program of physical activity. Physical activity may be a beneficial adjunct to more traditional care, and it may also alter your need for medication—thus it is important that your physician is informed of changes to your current physical activity level. The client’s physician must advise both the client and class instructor of any concerns they have regarding the introduction of both a new physical activity regimen. If you have any physical or emotional reaction to physical activity, discontinue the activity immediately, and contact the class instructor to ascertain if the reaction is adverse or an indication of the natural course of the body’s adjustment to the class training.

DESCRIPTION OF POTENTIAL RISKS: I understand that no exercise program is without inherent risks regardless of the care taken by a class instructor and that my personal safety cannot be guaranteed by my class instructor. I realize that when participating in any exercises, particularly those that induce cardiovascular stress, there is a slight chance of serious injury (e.g., heart attack, stroke, or other cardiovascular accidents) or catastrophic incident (e.g., death, paralysis). Likewise, I know that engaging in muscular endurance, strength building, and other fitness activities sometimes results in minor injuries (e.g., bruises, musculoskeletal strains and
sprains), less frequent, more serious injuries (e.g., muscle tears, herniated disks, torn rotator cuffs), and rarely, catastrophic injury (e.g., death, paralysis).

PARTICIPANT ACKNOWLEDGEMENTS
In agreeing to participation in this exercise class:

  • I acknowledge that my participation is completely voluntary.
  • I understand the potential physical risks involved in the exercise program and believe that the potential benefits outweigh those risks.
  • I give consent to certain physical touching that may be necessary to ensure proper technique and body alignment.
  • I understand that the achievement of health or fitness goals cannot be guaranteed.
  • I have been able to ask questions regarding any concerns I might have, and have had those questions answered to my satisfaction.
  • I am in good physical condition and have no impairment, which might prevent my participation in such activities.
  • I have been advised to cease activity immediately if I experience unusual discomfort and feel the need to stop

RELEASE OF INFORMATION: Client hereby authorizes the release of medical information discussed during any exercise consulting to his/her personal physician and pertinent healthcare professionals involved in their ongoing care, including copies of records needed for provision of care.

Patient understands that the physical activity guidance provided by the class instructor along with all printed physical activity material provided to them is solely for their use.

INSURANCE: HEALTH INSURANCE COVERAGE IS NOT ACCEPTED FOR PAYMENT AT THIS TIME. Medical insurance companies may or may not offer coverage for class training. Investigate the type of coverage that you have by calling the toll-free member services number on the back of your insurance card. It is the responsibility of the client to pay for their classes. However, a receipt shall be provided which may be self-submitted for potential insurance and/or healthcare savings account reimbursement.