Hands On Therapeutics
Adding Heart to the Healing Art and Sense to
Science
Informed Consent
Description Of The Exercise Program
I understand that my exercise program will involve participation in a number of types of fitness activities. I
understand that my personal trainer and physical therapist will work together to design a program that will have
activities tailored to my past health needs and my future health goals. These activities will vary depending upon
my goals and the objectives that my personal trainer, and physical therapist, but will include: 1)aerobic
activities including, but not limited to, the use of treadmills and stationary bicycles; 2)muscular endurance and
strength building exercises including, but not limited to, the use of free weights, resistant bands, weight
machines, calisthenics, and exercise apparatus; 3)other activities selected by my personal trainer and agreed
upon by me; and 4)selected physical fitness and body composition tests.
Description Of Potential Risks
I understand that no exercise program is without inherent risk regardless of the care taken by the personal
trainer and that my personal safety cannot be guaranteed by my personal trainer. I realize that when
participating in and exercises, particularly those that induce cardiovascular stress, there is a slight chance of
serious injury (e.g. heart attack, stroke or 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)
Description Of Potential Benefits
I understand that a regular exercise program has been shown to have definite benefits to general health and
well-being. I know that some of the benefits can include loss of weight, reduction of body fat, improvement of
blood lipids, lowering blood pressure, improvement of cardiovascular function, reduction in the risk of heart
disease, improved strength and muscular endurance, improved posture, and improved flexibility. I understand
that by working with a personal training in this medical setting my training will be more tailored to my medical
history and therefore has the potential to make more direct positive changes to my lifestyle.
Description Of Payment
I understand that by participating in a personal training program I am agreeing to pay the full cost of the
program (e.g. $70 for an hour). I understand that my insurance company will not pay any part of the cost of this
program and that I do not hold Hands On Therapeutics responsible for trying to contact outside sources for
payment. I understand and agree to make all payments in full and upfront.
Hands On Therapeutics
Participant Acknowledgements (please initial each statement):
____I acknowledge that my participation is completely voluntary and that there are 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 and fitness goals cannot be guaranteed and are dependent on
my willingness to comply with the set program.
____I understand that I have a voice in planning and approving the activities selected for my exercise program.
I understand that I have the ability to ask questions regarding concerns I might have and I have the right to get
those questions to the best of my satisfaction.
____I am in good condition, have no impairment which might prevent my participation in such activities, and
have been advised to consult with a physician prior to beginning the program.
____I am not taking any street/illicit drugs or other medications that may cause concerns or restrict my ability to
participate in personal training sessions.
____I have been advised to cease activity immediately if I experience unusual discomfort and feel the need to
stop.
____I understand that any information provided by the personal trainer is for educational purposes only and
should not be misconstrued as medical advice or diagnostically prescriptive in nature.
____I understand that my personal training session is not covered by my insurance company and that I am
responsible for the full cost of each session at the time of service.
____I understand that my personal training sessions are a division of Hands On Therapeutics. I understand that
Dr. Ravi Yadava and Performance Rehabilitation are completely separate entities from Hands On Therapeutics
and therefore share no liability, whatsoever, in the execution of this service.
____By signing this release, I hereby assume full responsibility for receipt of the personal training services and
release and discharge Hands On Therapeutics, and it’s staff, from any and all claims, liabilities, damages,
actions or causes of action arising from the training received including and without limitation, and damages
arising from acts of active or passive negligence on the part of the personal trainer to the fullest extent allowed
by law. This consent is noted to apply to all past, present, and future personal training sessions
Signature of Participant_______________________ Printed_______________________ Date_____________
Signature of Trainer________________________Printed___________________________Date____________