Consent Form
Essential Recovery Systems
Concussion Recovery Services Agreement, Informed Consent & Liability Waiver
Client Name
Date of Birth
Date
1. Scope of Services
I understand that ERS Essential Recovery Systems ("ERS") provides neuromuscular therapy, recovery support, and performance optimization services related to concussion and post-concussion symptoms.
Services may include:
- Initial assessment and intake
- Hands-on neuromuscular therapy
- Movement-based interventions
- Recovery protocols and recommendations
- Follow-up sessions and progress evaluations
These services are non-medical in nature and are intended to support recovery, not replace medical care.
2. Medical Acknowledgment (Critical for Concussion Work)
I acknowledge that:
- Concussions and brain injuries are medical conditions requiring oversight by a licensed healthcare provider
- ERS does not diagnose, treat, or cure medical conditions
- I have been advised to consult with a licensed physician prior to beginning services
If I choose not to seek medical care, I do so at my own risk.
3. Informed Consent & Assumption of Risk
I understand that participation in ERS services involves inherent risks, including but not limited to:
- Symptom fluctuation (headache, dizziness, fatigue)
- Temporary increase in discomfort
- Neurological sensitivity or delayed response
- Physical soreness or tension changes
I knowingly and voluntarily assume all risks associated with participation.
4. Client Responsibility & Full Disclosure
I agree that I am fully responsible for:
- Providing accurate and complete health history
- Disclosing prior concussions, neurological issues, or medical conditions
- Informing ERS immediately of any worsening symptoms
- Following or choosing not to follow recommendations at my own discretion
Failure to disclose relevant information releases ERS from related liability.
5. No Medical Claims or Guarantees
I understand:
- Results vary significantly between individuals
- No specific outcomes are guaranteed
- Recovery timelines are unpredictable, especially with concussion-related conditions
6. Release of Liability
To the fullest extent permitted under the laws of New York and Massachusetts, I hereby release and hold harmless ERS Essential Recovery Systems, its owner, practitioners, and affiliates from any and all claims, liabilities, damages, or causes of action arising from:
- Participation in any ERS service
- Implementation (or non-implementation) of recommendations
- Any physical, neurological, or emotional response to services
This includes claims of negligence, except where prohibited by law (such as gross negligence or willful misconduct).
7. New York & Massachusetts Legal Notice
I understand that:
- Some liability protections may be limited under state law
- This agreement is intended to be as broad and enforceable as legally permitted
- Any unenforceable portion shall not affect the remainder of the agreement
8. Session Flow Acknowledgment
I understand that ERS services follow a general structure:
- Assessment
- Intervention / Treatment
- Reassessment and Follow-Up
I acknowledge that my participation at each stage is voluntary and may be stopped at any time.
9. Emergency & Medical Escalation
ERS practitioners may recommend stopping a session or seeking medical care if symptoms indicate risk. I agree that:
- ERS is not responsible for emergency medical decisions
- I am responsible for seeking urgent or ongoing medical care when needed
10. Governing Law
This agreement shall be governed by and interpreted under the laws of the State in which services are rendered (New York or Massachusetts).
11. Consent to Treatment
I voluntarily consent to receive services from ERS Essential Recovery Systems and confirm that I have read, understood, and agreed to all terms.
Client Signature (type full name)
Date
ERS Practitioner Signature (type full name)
Date