CONSENT FOR CARE
I hereby give consent for Nurturing Water Therapies, LLC to provide aquatic therapy/adapted aquatics to me/my child/my dependent for the above noted condition(s) as recommended by my aquatic therapist.
I understand that the aquatic therapist does not diagnose illness or disease and does not prescribe medical treatment or pharmaceuticals.
I understand that aquatic therapy is not a substitute for medical care and that it is recommended that I work with my primary care physician and other healthcare providers for any condition I may have.
I hereby give Nurturing Water Therapies, LLC permission to discuss my/my child/my dependent’s case with involved professionals. I also understand that services are performed in a public place and in plain view of non-care related persons.
CAREGIVER PRESENCE DURING SESSIONS
I understand that if my child/my dependent is under 18 years old or require assistance with dressing, showering or walking between the pool and shower/restrooms or has severe medical issues, I or a caregiver will always be present during each session.
I understand that Nurturing Water Therapies, LLC does not bill insurance company/companies on my behalf. I am financially responsible for services provided by Nurturing Water Therapies, LLC and agree to remit payment to Nurturing Water Therapies prior to my appointment. I understand and agree that if I fail to make the payment in a timely manner, I will not be able to see my therapist at the agreed upon date and time.
CANCEL/NO SHOW POLICY
I understand and agree that if I fail to cancel or reschedule my/my child/my dependent’s appointment less than 24 hours in advance, I will pay the $30.00 no-show charge for a 25- min session, $45.00 for a 45-min session or $55.00 no-show charge for a 55-min session.
I understand and agree that if I cancel my/my child/my dependent’s appointment more than 24 hours in advance, I will be refunded the full amount for the missed appointment unless it was rescheduled to another date and time.
USE OF THIRD PARTY SOFTWARE
Nurturing Water Therapies works with another company and their website to provide our clients with an opportunity for more efficient service and scheduling. We believe that the site (QuickBooks) take reasonable precautions for users, but we cannot be responsible for the security of third party sites which we do not manage. If you have concerns please tell us and we can work with you without using those sites.
NOTICE OF PRIVACY PRACTICES
By signing below, I certify that I have read Nurturing Water Therapies, LLC’s Notice of Privacy Practices.
I understand there are risks associated with the use of the pool. I am aware of these risks and agree that my/my child/my dependent’s participation is at my/their own risk. I, for myself, my heirs and assigns, hereby release Nurturing Water Therapies, LLC, any pool where Nurturing Water Therapies, LLC does business, their owners and employees, from any and all actions, costs, suits, demands, claims, damages, losses, and liabilities connected to my/my child/my dependent’s participation in the water-based therapies, exercises and swim lessons where Nurturing Water Therapies does business. This includes reasonable attorney’s fees of any type arising out of or caused by my/my child/my dependent’s participation in such activities. I also represent and warrant that I have obtained approval from my/my child/my dependent’s physician to participate in the program and/or referral by a qualified professional. I understand that I cannot be in the pool with my therapist if I have any of the following:
I understand that the pools where Nurturing Water Therapies, LLC provides services have rules and regulations and agree to abide by them completely. I, for myself, my heirs and assigns, release Nurturing Water Therapies, LLC from all future claims and causes of action occurring as a result of personal injuries sustained by me/my child/my dependent as a consequence of using the facilities. I agree to cooperate fully with any request of the staff.