Terms & Conditions

By booking a service or class with Jennifer Sylvester DPT, you agree that you have read and consent to the following:

 

1.

By signing this form, I acknowledge that, with respect to Wellness & Fitness services rendered by Jennifer Sylvester, PT, DPT, and her employees and agents (collectively “Physical Therapist”), I understand the following.

California law defines physical therapy to include "the promotion and maintenance of physical fitness to enhance the bodily movement related to health and wellness of individuals through the use of physical therapy interventions.”

Services related to wellness and fitness may include instruction in general flexibility, strength and conditioning exercise programs for home/clinical/health club settings, geriatric wellness exercise programs for individuals and groups and ergonomic or other educational programs for industry or private organizations.

Physical therapy interventions that are reasonably designed and intended, consistent with applicable professional standards, to promote or maintain physical fitness and not to treat or correct a medical condition may be employed by a physical therapist without any diagnosis by another health care practitioner.

I recognize that:

• Fitness programs require physical exertion which may be strenuous and may cause physical injury. Risks, dangers, and hazards include property damage, bodily injury, strains, fractures, partial or total paralysis, serious disability, or death. I am aware of the risks and hazards involved. Benefits include strength, balance, and endurance, as well as boosts in energy, mood, sleep, and overall wellness.

• It is my responsibility to consult a physician prior to and regarding my participation in a one-on-one exercise program. I represent and warrant that I am physically fit and that I have no medical condition that would prevent my full participation in the exercise program.

• Physical Therapist makes no representations, claims or guarantees that my medical problems or conditions will be cured, solved, or helped by receiving fitness and wellness services from Physical Therapist. Physical Therapist is not responsible for the condition of space and equipment rented by Physical Therapist but owned by a third party.

• I knowingly, voluntarily, and intelligently decide to receive the services described above, and I knowingly, voluntarily, and intelligently assume all risks involved in the same. As a result of my assumption of these risks, I agree to release, hold harmless, indemnify, and defend Physical Therapist from and against any and all claims which I (or my representatives) may have for any loss, damage, or injury arising out of or in connection with use of the services described above. I agree not to pursue a claim against Physical Therapist, simply because I am dissatisfied with the results of the above services.

• Any claim relating in any way (including through use of space of equipment) to Wellness & Fitness services provided by Physical Therapist (including but not limited to any claim of negligence, wrongful death, or property damage), will be determined by submission to arbitration, administered by the American Health Lawyers Association (AHLA) Alternative Dispute Resolution Service and conducted pursuant to the AHLA Rules of Procedure for Arbitration. Judgment on the award may be entered and enforced in any court having jurisdiction. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

2.

I hereby grant to Jennifer Sylvester DPT (“DPT”), permission to the rights to reproduce my image, likeness, sound, and written work, as recorded on audio, videotape, in writing, multi-media or in any medium (the “Recording”):

Human body features will be viewable, and identifiable facial features will be viewable. I may be identifiable from such photograph or videotape. I waive the opportunity to review and approve the use of such photographs and/or videotapes before they are used in this manner.

I hereby understand and authorize that the Recording may be edited, copied, exhibited, published, or distributed by DPT without limitation (including but not limited to publications, websites, webcasts, advertisements, presentations, DVDs, etc.). I waive the right to inspect or approve the finished product. I understand these materials become the property of DPT and will not be returned. My full name and title may be revealed in conjunction with the Recording. DPT may also summarize or shorten statements or other material as needed in its sole editorial discretion, and may feature personal items with the Recording.

I understand that there will be no payment or any other compensation or consideration for the Recording, and I waive any right to royalties or other compensation arising or related to the use of the Recording. I also understand that the Recording may be used in diverse settings within an unrestricted geographic area; that there is no time limit on the validity of this release nor any geographic limitation on where these materials may be distributed; and the above may be used, disclosed, and displayed via the Internet or otherwise in the public setting. I understand that I am providing the Recording to DPT and that my treating clinician will not be providing any information, the confidentiality of which may be protected by federal and state statutes and regulations, including, as applicable, Health Insurance Portability and Accountability Act (HIPAA).

By signing this form I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I further agree to release, discharge, and indemnify DPT from any legal proceedings that may arise in relation to the conditions stated above.

I understand that I have the right to revoke this Release by giving DPT written notice and that revocation of this Release will not affect any action DPT took in reliance on this Release before receiving my written revocation.

 

3.

Refunds may be issued upon written request from the time of service registration up to 24 hours in advance of the appointment. After that time, fees may not be refunded. If you would like a refund for any reason prior to the 24 hours before your appointment, please contact Dr. Jen directly by calling (408)550-7226 or emailing DrJen@JenniferSylvesterDPT.com

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