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KSB Health, Inc. Consent to Treat Form

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By checking this box, I understand that this consent to treat form applies to KSB Health, Inc. *Please check it here.

By checking this box, I consent to treatment and care by KSB Health, Inc. and the licensed and certified athletic trainer employees on staff. This includes orthopedic assessments which consist of history questions, palpations, manual muscle testing, range of motion, and special tests. This also includes treatments offered by KSB Health, Inc. such as dry needling, manual therapy, cupping, stretching, myofascial release/muscle scraping, electrical stimulation,recovery boots, and massage gun. I acknowledge that no guarantees have been made as to the effect of such treatment and care on my condition. I understand the risks related to any treatments. *Please check it here.

By checking this box, I assume responsibility for personal property brought with me. *Please check it here.

By checking this box, I agree to hold harmless KSB Health, Inc. and its employees from any and all liability in the case of an accident, injury, damage, or other mishap in connection with all services provided to me. *Please check it here.

By checking this box, I understand that consent is being given in advance to any specific diagnosis and/or treatment and intend this consent to be continuing in nature even after a specific diagnosis has been made and/or a treatment recommended. *Please check it here.

By checking this box, I understand that payment must be made in full immediately following completion of treatment session. *Please check it here.

Do you authorize KSB Health, Inc. to take photographs and/or videos of you and grant permission for these to be utilized on social media for promotional and educational purposes? *

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