WARNING - Waiver Has Not Been Signed - Please confirm this action
Active Release Technique Waiver
*Emergency contact Name: *Number
Your Exercise Past and Present
*Are you currently Exercising: Yes No
What are you doing:
*Have you exercised in the past: Yes No
What were you doing:
Health and Injury
Do you suffer from: (tick appropriate box)
*Any other conditions that may prevent you from safely exercising:
Are you Pregnant: In what trimester: 1st 2nd 3rd
Are you over 45?
How did you hear about ART?
*Have you had clearance from your doctor to exercise: Yes No
I, , have voluntarily chosen to participate in manual therapy at Lift Performance Centre and have answered the questions above to the best of my ability and affirm that my physical condition is good and I have no known conditions that would be adversely affected by treatment. I acknowledge that any information given by the practitioner is an opinion and not a diagnosis of any condition. Furthermore, I agree to self determine my exertion through good judgment and to discontinue any movement or protocol that exceeds my personal limitations and will advise the practitioner. I understand that by signing this agreement that I hereby waive Lift Performance Centre, its Director, staff, and all relevant employees as well as my practitioner in any way from liabilities or demands as a result of injury, loss, or adverse health conditions as a result of my treatment.
*I affirm that I have read and understand this document and I wish to participate in fitness activities.