KinoFit Patient Consent Form Name Name First Name First Name Last Name Last Name Email Phone Date of Birth Acknowledgment of Services I understand that KinoFit Physical Therapy, PLLC is offering complimentary physical therapy screenings and movement assessments at this public health fair. These services may include, but are not limited to: Postural assessments Movement screenings Flexibility and mobility testing Strength and balance evaluations General wellness recommendations I understand that these services are informational and educational in nature only and do not constitute a full physical therapy evaluation, diagnosis, or treatment plan. Medical Disclaimer & Assumption of Risk I acknowledge and agree that: I am voluntarily participating in this assessment. I am responsible for informing the provider of any existing injuries, medical conditions, or physical limitations. The screening is not a substitute for medical advice, diagnosis, or treatment from a licensed physician or healthcare provider. Participation may involve minor physical exertion, which carries inherent risks such as muscle soreness, strain, or injury. I assume full responsibility for any risks, injuries, or damages that may occur as a result of my participation. Release of Liability In consideration of being permitted to participate, I hereby: Release and discharge KinoFit Physical Therapy, PLLC, its owners, employees, contractors (including Dr. Jamar Smith, PT), and affiliates from any and all liability, claims, demands, or causes of action arising out of or related to my participation. Agree not to hold KinoFit Physical Therapy liable for any injury or adverse outcome that may occur. Consent to Participate By signing below, I confirm that: I have read and fully understand this form. I voluntarily consent to participate in the assessment. I am physically able to engage in light physical activity. Media Release Authorization (Optional but Recommended) I grant permission to KinoFit Physical Therapy, PLLC to: Capture photographs, video, and/or audio recordings of me during the event Use these materials for marketing, promotional, educational, and social media purposes, including but not limited to website content, advertisements, and publications I understand that: My name may or may not be used in association with the media I will not receive compensation for the use of these materials All media will remain the property of KinoFit Physical Therapy, PLLC * Yes, I consent to media use No, I do not consent to media use Signature signature keyboard Clear Date Submit If you are human, leave this field blank.
