Pop-Up Clinic Waiver
Pop-up clinics provided by Charlotte Dance Medicine (CDM) are intended for educational and screening purposes, with brief testing, movement assessment, and treatment as deemed appropriate by the CDM physical therapist present at the time of appointment. Pop-up clinics are not intended to delay or substitute for medical advice, diagnosis, or comprehensive treatment from a physical therapist or other healthcare professional. During the pop-up clinic, recommendations may be made, including but not limited to dance modifications and referral for physical therapy evaluation or to additional healthcare providers.
Informed Consent to Participation in Pop-Up Clinic
1. I do hereby voluntarily consent to pop-up clinic services provided by CDM in the manner in which they are intended and described in the disclaimer statement above.
2. I am aware that the pop-up clinic environment may unintentionally expose my status as a participant.
3. I understand that inherent risks are possible, as in all healthcare practices, including but not limited to: changes to vitals, pain, and muscle soreness. I accept that the physical therapist will act in my best interest but cannot always anticipate individual reactions.
4. I accept that the physical therapist, CDM, nor the hosting facility are liable for any injury or damages to person or property resulting from participation in the Pop-Up Clinic.
5. I confirm that all information disclosed, including current injuries and ongoing medical issues, is complete and updated to the best of my knowledge, and I agree to update the physical therapist and CDM immediately with any changes.
Notice of Privacy Practices
This notice describes how medical information about participant may be used and disclosed. All healthcare entities are required by law to maintain the privacy of protected health information, to provide clients with notice of this requirement, and to abide by the privacy policies and practices outlined below:
1. Screening/Treatment: Your health information without personal identifiable factors may be disclosed to other healthcare professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment.
2. Healthcare Operations: Your health information may be used as necessary to support the day-to-day activities and management of CDM including but not limited to budgeting/financial planning.
3. Law Enforcement/Public Health Reporting: Your health information may be disclosed to public health agencies, without your permission, to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government mandated reporting including report of certain communicable diseases.
Media/Public Relations Authorization for the Use and Disclosure of Protected Health Information
1. I authorize CDM to disclose to media representatives and/or public affairs staff members my protected health information including status of and reason for my participation for purposes of publicity, promotion, education or publication in print, broadcast and electronic and social media. I understand this authorization includes my likeness on photo, videotape and digital media.
2. I understand that I have the right to inspect and copy my own protected health information to be used or disclosed.
3. I understand that I will not be compensated in any way for the taking or use of photographs, films, audio and/or videotapes, or the publishing of any article or information.
4. I understand that I have the right to revoke this Authorization at any time by writing a notice of revocation to: admin@charlottedancemedicine.com. I understand that such revocation shall be effective for future uses and disclosures, but such revocation shall not be effective for information already used or disclosed. I understand that once health information is used or disclosed, it is no longer protected by state or federal law.
Preparing for the Pop-Up Clinic
1. A parent is strongly encouraged to be present for the duration of the appointment for dancers under age 18 or those still in high school, as well as parents making healthcare decisions for dancers age 18+.
2. Participants are asked to wear loose fitting clothing that allows movement and access to skin surrounding area(s) of concern.