LIC Springs | FMS | True North Physical Therapy | New York

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True North Physical Therapy, Physical Therapy New York, Physical Therapist New York, Physical Therapist New York City, Physical Therapy New York City

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LIC Springs | FMS Waiver | June 18th 2022

First Name

Last Name

Email

I am 18+ years old and/or I have parental consent to participate

No

Yes

I hereby acknowledge this release of, True North Physical Therapy PLLC, from liability for accidental injury or illness which I may incur as a result of participating in any physical activity. I hereby assume all risks connected therewith and consent to voluntarilarly participate in this program.

I declare that the info I’ve provided is accurate & complete

Initials

5-31 50th Ave

Long Island City, NY 11101

Mon -- Sat | By Appointment Only

True North Physical Therapy, Physical Therapy New York, Physical Therapist New York, Physical Therapist New York City, Physical Therapy New York City

P: 732.861.5543

F: 646.839.2973

info@truenorthpt.com

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