CLIENT RESPONSIBILITIES By checking this box , you, the client and responsible party (if applicable), agree to the following terms and conditions that will serve as the agreement upon which “Pelvic Wellness Services” will be provided to you by Hayley Kava PT, MPT, L.L.C. (Hayley Kava PT, MPT, “us” or “we”). YOUR RESPONSIBILITIES 1. Health Information. You have the responsibility for providing accurate and complete information about medical complaints, past illnesses, hospitalizations, medications, pain, and other matters relating to their health. We may ask you to obtain a written medical clearance from your physician prior to commencing and/or resuming services from us. We reserve the right to withhold further scheduling of services until you are cleared by your physician and proof of such has been provided to us at least 48 hours prior to your next appointment. 2. Pelvic Wellness Plan. As a client, you have a right to give informed consent and vocalize any pain/discomfort or concerns that you have with wellness services provided. You are an intricate part of your care. Your full participation is required to achieve the desired fitness and wellness goals. You also understand that results are never guaranteed. Pelvic wellness services are NOT Physical therapy services we can discuss concerns, provide education, provide resources, modify or create a training program that will help you meet your fitness and wellness goals with your specific needs/concerns in mind. These services are ideal for someone who has been evaluated for pelvic floor problems by provider as well as a pelvic floor PT but is looking for a more global and movement based approach in order to meet their wellness/fitness goals 3. Scheduling/Arrival. It is your responsibility to schedule and attend appointments in accordance with your wellness plan. You are expected to be dressed in appropriate clothing and ready for your appointment five (5) minutes prior to your scheduled appointment time. Appointments will start promptly at scheduled time. via secure video streaming service 4. Missed/Late Appointments/Cancellations. Your failure to be prepared for your appointment on time will cause the following to occur: 1) your appointment time will not be extended; and 2) you will be billed for a full appointment irrespective of the actual start time. Please provide at least 24 hours notice if needing to cancel an appointment. “No-Shows” will be noted if you are not present and ready within 15 (fifteen) minutes of the agreed upon start time. We reserve the right to discontinue your treatment if you have two (2) no-shows or cancellations with less than 24 hours notice. In the event of inclement weather, we may cancel or reschedule your appointment in the interest of safety. 5. Rates. Rates are subject to change. Current rate: $ 120 Initial Wellness Consult (60 mins) $100 Follow-up wellness visits (60 mins) These services also include email communication and home program information 6. Payment. Payment is due at time of treatment. Services are not eligible to be billed through any third-party payor/insurance (Tricare, Blue Cross, Medicare, Medicaid, Workers’ Compensation, other health insurance or payors). You will be solely and fully responsible for the charges incurred. We have a strict “no refund” policy. We accept payment by cash or credit card (Visa or Master Card.) Payment must be received in order to schedule your next appointment. There is a $35 bounced payment fee for payments that cannot be processed which will be assessed to you and due immediately. If a payment plan is needed, details will be agreed on between you and Hayley Kava PT, MPT. We reserve the right to report non-payment to any credit reporting agency. We reserve the right to seek costs of enforcement and collections, including attorneys’ fees, from you in the event that your non-payment incurs us such costs. If Client is not responsible for payment, then the “Responsible Party” designated on the signature page of this agreement shall be bound to the terms outlined in this Sections 6 and 7. 7. Limitation of Liability. We are dedicated to preventing further injury and promoting your wellness journey but this can only be done with your full disclosure and cooperation. By initialing this section, you understand and agree that you are engaging our services for health and wellness promotion. As such, you are not seeking our services outside of the recommendation of a licensed medical doctor. You have fully disclosed to us all health-related information that is pertinent and necessary for proper consideration in creating a wellness plan. In the event that you have a specific health condition, you have also disclosed the possible ramifications of such condition as it pertains to the structure and integrity of your skeletal, muscular and nervous systems. If necessary, you have provided us with your full medical records including x-rays and MRIs along with the appropriate physician notations to properly explain observations about your specific case. It is your obligation to immediately stop any proposed course of exercise/recommendation that causes you discomfort or pain and to immediately notify Hayley Kava of such. It is your obligation to immediately stop therapy in the event that you experience an injury—whether in the course of receiving treatment or outside of treatment. Failure to abide by these terms will result in forfeiture of any action or claims that you may seek against us as it relates to services provided to you and shall serve to hold us harmless from any and all such claims. 

8. Practice Guidelines. Our goal is to further your wellness and fitness goals. In some cases, the exercises recommended may be challenging. We strive to work with you to overcome physical hurdles and frustrations. As such, we expect that d staff will be treated respectfully at all times. This means that you will be open to Hayley Kava’s recommendations and be fully present, without interruption, during your scheduled appointment time. We reserve the right to withdraw from providing you physical therapy services at our sole discretion. For purposes of illustration but not limitation, this may occur if: we discover that you are engaging in or undertaking in a course of action that may be detrimental to your health or treatment plan; you fail to adhere to your therapist’s advice; the client-therapist relationship is compromised in any way; communication issues render it difficult for the therapist to perform services; you miss appointments or are consistently late to appointments. 9. Privacy Policy and HIPAA. From time to time it may be necessary for us to use and disclose protected health information (PHI) about you to carry out your wellness plan, payment and health care operations (TPO). By signing this document, you understand that we may call your home or other alternative location and leave a message on voice mail in reference to any items that assist Hayley Kava PT, MPT in carrying out TPO, such as appointment reminders and any calls pertaining to my clinical care, among others. Further, we may mail to your home or other alternative location requested by you, any items that assist the practice in carrying out TPO, such as appointment reminder cards and client statements as long as they are marked “Personal and Confidential.” We may e-mail to your home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and client statements. By signing below, you agree to all of the terms outlined above as a strict condition to obtaining physical therapy services, and further accept full financial responsibility as a client or as the Responsible Party (guarantor) for such client

Pelvic Wellness Waiver Form This Waiver and Release is between Hayley Kava PT, MPT , LLC (“Hayley KavaPT, MPT”) and the undersigned Participant (“Participant”) and, if Participant is under the age of 18, the Participant’s parent or legal guardian (“Parent”). For valuable consideration, the receipt and legal sufficiency of this is acknowledged by their signatures below. Hayley Kava PT, MPT, Participant, (and parent) each agree: Waiver, Release, and Indemnity: By signing this Release; Hayley Kava PT, MPT, Participant, (and Parent) each waive and assume all risks of participation in physical therapy services and covenant not to bring legal action against Hayley Kava PT, MPT for any and all bodily harm or other incident relating to services provided by Hayley Kava PT, MPT