San Marino Foundation Session Intake Form
Waiver of Liability and Acknowledgment of Risk
Risk Acknowledgment:
I understand that participating in activities and using facilities at Village Fitness and Physical Therapy, Inc. (“Village”) involves inherent risks such as bodily injury, illness, or potentially death. These risks may arise from various causes, including but not limited to, the negligence of Village staff or other participants. I voluntarily assume these risks by engaging in Village activities or using its facilities and equipment.
Release of Liability:
I hereby release and hold harmless Village, its employees, and representatives from any claims of injury, property damage, or wrongful death, whether caused by negligence or any other reason, arising from my participation in Village activities or use of Village facilities. This waiver applies to me, my heirs, and my personal representatives.
Payment and Insurance Disclosure:
I understand that payment is due at the time of service and that Village does not bill insurance directly. Village is a non-participating Medicare provider and does not submit claims for Medicare-covered services. All services provided are considered non-covered under Medicare and other insurance plans. Receipts are available upon request but may not meet the documentation standards required for insurance claims.
Cancellation Policy:
To respect the time of our providers and other clients, Village has a 24-hour cancellation policy. If I need to cancel or reschedule a session, I will provide at least 24 hours’ notice. If I cancel with less than 24 hours' notice, I understand that I may be responsible for the full session fee.