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Client Consent Form

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EMPOWERPHYSIOPET SERVICE AGREEMENT

This Agreement is between Amie Lamoreaux Hesbach PT DPT CCRP CCRT, EmpowerPhysio/EmpowerPhysioPeT, of 2 Chandler St. Maynard, MA 01754 (“Hesbach”) and ___________________________________ of ___________________________________, Massachusetts (“Client”).

 

Hesbach agrees to provide physical therapy services on consultation to Client’s pet known as ______________________________.

 

Hesbach shall perform consultative services as follows:

Physical therapy evaluation of neuromusculoskeletal dysfunction.

Physical therapy treatment, which may include one or more of the following:

__Therapeutic exercise.

__Manual therapy (joint or soft tissue mobilization).

__Neuromuscular electrical stimulation (NMES).

__Low Level LASER Therapy (LLLT).

__Biomechanical movement analysis for sport or work performance.

__Home exercise program instruction.

__Orthotic and assistive device assessment.

__Periodic re-assessment of progress and tolerance of treatment.

 

Client shall pay as follows:

Initial Evaluation: $150.

Each individual treatment session (up to one hour in length): $100.

Additional travel surcharge (as designated by Hesbach).

 

Payment is due at time of service.

 

HESBACH MAKES NO WARRANTY, EXPRESS OR IMPLIED, WITH RESPECT TO THE SERVICES PROVIDED HEREUNDER.

 

HESBACH’S ENTIRE LIABILITY OF ANY KIND, WHETHER IN CONTRACT, TORT OR OTHERWISE, ARISING FROM THE SERVICES PROVIDED HEREUNDER SHALL NOT EXCEED THE TOTAL CHARGES PAID TO HESBACH FOR THE SERVICES PROVIDED.

 

IN NO EVENT SHALL HESBACH BE LIABLE FOR ANY SPECIAL, INCIDENTAL, INDIRECT OR CONSEQUENTIAL DAMAGES.

 

This Agreement shall be governed by the laws of the Commonwealth of Massachusetts.

 

 

                                                   Amie Lamoreaux Hesbach, PT, DPT, CCRP, CCRT    

 

                                                                   Client 

 

_________________________Date