Updated Oct. 12, 2020
This electronic form serves as the informed consent document for the Childbirth Prep Class provided by Alex Courts with Vibrant Physical Therapy & Wellness, LLC.
Disclosure of Information
1. I hereby authorize Alexandra Randolph Courts to perform the following childbirth education class and other similar techniques on me: education and virtual demonstration and feedback. In addition, I authorize the instructor to perform the following treatments and/or procedures related to any wellness services: health and wellness coaching, education, general comfort measures instruction, general positioning instruction, and general exercise instruction and feedback. I understand that these procedures are being performed to: inform me, reduce risk of injury and complications, improve physical function and mobility, reduce pain, and improve health and wellness. Furthermore, the risks associated with these procedures or treatments include: soreness, stiffness, fatigue, pain, bruising, swelling, injury, increasing risk of sudden cardiac arrest with vigorous exercise in those with cardiovascular disease.
Limitations on Authorization
- This authorization does not extend to the performance of the following treatments and/or procedures: physical therapy. No evaluation or individual plan of care is being created. Information provided is for general educational purposes.
Expansion of Authorization
- During the course of my treatments and/or procedures, I understand that unforeseen conditions and/or complications may arise or be discovered which require additional or different treatments and/or procedures than those specifically consented to above. Therefore, I further authorize the above named allied healthcare provider, and such other assistants or designees as may be selected by the allied healthcare provider who is to perform the procedure or treatment, to perform such other procedures as may be medically necessary and advisable in his or her best professional judgment.
Disclaimer of Particular Result
- I am aware that individual outcomes cannot be guaranteed and I hold the provider harmless for any and all and all labor and delivery complications. I am aware that the childbirth prep class provided by Alexandra Randolph Courts is limited to providing general information about positioning, movements, and breathing options that MAY reduce risks during labor and delivery.
5. I hereby acknowledge that I have been informed of the nature, purpose, risks, and expected results of this childbirth prep webinar. I acknowledge that the content of this childbirth prep webinar should not be construed as giving specific medical advice and all specific medical advice is deferred to the client’s physician/provider in order for the client to make informed consent medical decisions during labor and delivery. All of my questions regarding these treatments and procedures have been answered in a satisfactory manner. I have read and understand this agreement. I realize that by signing this informed consent I am consenting to the performance of the procedures noted herein. Furthermore, I am aware that I have a right to withdraw my consent to any of the above-mentioned procedures at any time before or during treatment. I further acknowledge that by typing my name, this is considered a legal and binding document. Please sign by typing your name when prompted in the registration section on the Eventbrite Site.
If you would like an electronic copy of the informed consent, please complete email us at firstname.lastname@example.org to request a separate online form.