Name

First Name

Last Name

Phone

(###)

###

####

Event

Daffodil Run

Gold Crush Climbing Event

10th Planet Jiu Jitsu

Have you ever been treated by a Radius provider?

Yes

Informed Consent for Athlete Services

By signing below I am consenting to have a Radius provider perform a clinical assessment to include orthopedic, neurological, and muscle testing for the purpose of educating me on my condition. I understand this assessment is not intended to diagnose or treat any current injury or condition. The information I am about to receive and any manual therapy, manipulation, or other treatment modality used is only for education and general wellness. I have had the opportunity to discuss with the provider the purpose and benefits of the recommended care and alternatives have been reviewed. I have had ample opportunity to ask questions, and my questions have been answered to my satisfaction. I hereby voluntarily consent to participate in this assessment, which will be performed by authorized Radius personnel.

Photo & Video Release and Consent

I understand that if any photographs and/or video of me are taken, they may be used for promotional/marketing purposes, and I hereby authorize Radius Physical + Sports Rehab to publish images taken of me for the use in print, online, and video-based marketing materials and other publications. I understand I may revoke this at any time, but revocation must be done in writing. This authorization expires ninety-nine years from date signed.

Electronic Signature

By typing my name below, I agree that it acts as an electronic signature, and confirms I have read and agree to the information presented to me in this form.

EVENT WAIVER FORM

Thank you for participating!

Sit tight. A Radius provider will be with you shortly.

Instantly see our availability for New Patients and Existing Patient appointments.

No referral required. We take insurance.

Nevada City/Grass Valley:

(530) 955-0065

Event Waivers