Acknowledgement & Assumption of Risk

I understand that I am being asked to carefully read each of the provisions in this form. I acknowledge and agree to have receive therapy services from Branched Out Therapy, Inc. and/or any employee or independent contractor employed by Branched Out Therapy, Inc.
I acknowledge that there is some inherent risks associated with the use of therapy equipment that cannot be eliminated regardless of the care taken to avoid injuries.
I understand the risks and I hereby assert that my participation is voluntary and that I knowingly assume such risks without holding Branched Out Therapy, Inc. and/or any employee or independent contractor employed by Branched Out Therapy, Inc. accountable for any losses, injuries or other damages occurring to the client and/or myself. I further understand that I am fully responsible for my own safety.

Layout

Signature of Client or Legal Representative *

Relationship to Client *

Ready to Improve Your Speech & Language?