ACKNOWLEDGEMENT & CONSENT

I fully understand and acknowledge that (a) the activities in which I will engage as part of the treatment provided by Jayna Lehman-Williams and the equipment I may use as a part of that treatment have inherent risks, dangers, and hazards and such exists in my use of any equipment and my participation in these activities; (b) my participation in such activities and/or use of such equipment may result in injury or illness including, but not limited to, bodily injury, disease, soreness, strains, numbness, tingling, muscle tears, fractures, partial and/or total paralysis, death or other ailments that, could cause serious disability; (c) I hereby assume all risks and dangers and all responsibility for any losses and/or damages whether caused in whole or in part by the negligence or the conduct of Jayna Lehman-Williams; (d) I know that I have the right to choose what treatment I do or do not receive, in addition to withdrawing from treatment at any time; (e) I recognize that my participation in the activity covered hereby is conditioned upon my signing and returning this waiver and release.

​

I, on behalf of myself, my personal representatives and my heirs, hereby voluntarily agree to release, waive, discharge, hold harmless, defend, and indemnify Jayna Lehman-Williams, and assigns from any and all claims, actions or losses for bodily injury, property damage, wrongful death, loss of services or otherwise which may arise out of my use of any equipment or participation in these activities. I specifically understand that I am releasing, discharging, and waiving any claims that I may have presently or in the future for the negligent acts or other conduct by Jayna Lehman-Williams.

​

I understand that I may show this INFORMED CONSENT and WAIVER & RELEASE OF LIABILITY to, and consult with, my own independent legal counsel before signing.

​

Consent: I consent to and authorize Jayna Lehman-Williams to administer physical therapy treatment. I understand and am informed that, as in the practice of medicine, physical therapy may have some risks. I understand that I have the right to ask about these risks and have any questions about my conditions answered prior to treatment. I know it is up to me to inform the physical therapist/staff about any health problems or allergies I have, as well as medications I am taking.

 

I HAVE READ THE ABOVE WAIVER AND RELEASE AND BY SIGNING IT AGREE. IT IS MY INTENTION TO EXEMPT JAYNA LEHMAN-WILLIAMS FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH BY ANY CAUSE.

​

APPOINTMENTS

Please be aware that a portion of your appointment time may be spent discussing your home program, scheduling further visits, conducting payments, or further explaining the treatment plan.

​

CANCELLATION

Please provide at least 24 hours notice if you are unable to attend your appointment. Cancellation and/or rescheduling may be completed via phone call, text, or online. Failure to do so will result in being charged for the appointment. 

 

COVID

Covid-19 cleanliness precautions are being taken prior to each client. Please do not bring any guests with you, unless approved.

• Masks must be worn at all times.

• Bring as little to session as possible.

• You will be subject to a temperature check. 

 

If you are not feeling well or have come into contact with anyone who has tested positive in the past 14 days, please cancel your appointment 24 hours prior to avoid cancellation fee. 

​

If vaccinated, please show proof of BOTH vaccinations. You will still be required to wear a mask. Each of these statements may be repeated.

I appreciate your support during this time. I am fully vaccinated and will do my very best to ensure you feel safe and comfortable.
 

INSURANCE

Jayna Lehman-Williams does NOT contract or participate with insurance companies. Please be aware prior to initial evaluation. By booking services, you understand that you are financially responsible for all charges.

 

Upon request, patients may be provided a copy of their bill. This may then be submitted to their insurance company for reimbursement. Jayna Lehman-Williams is not responsible for obtaining referrals and/or pre-authorizations that insurance companies may require.

​

Upon request, patients may be provided a copy of their chart for medical records.

​

LATE APPOINTMENTS
Please arrive on time to your appointment. If you believe you will be late, please contact via phone call or text. You will still be allotted the remainder of your time slot but will be charged for the full visit. 

​

MILEAGE

Jayna Williams Physiotherapy reserves the right to charge additional fees depending on mileage.

​

PATIENT REGISTRATION

Patients must complete the patient registration form prior to their first session: https://forms.gle/GQ1Yc59NnWmp9ZUo7. You may be asked to complete this registration again in the future to ensure we always have current information on file for you.

​

PHOTOGRAPHY CONSENT

Jayna Williams Physiotherapy reserves the right to photograph sessions, unless patient explicitly states otherwise. 

​

​