🩺 KINEMATICS WITH KELLY, LLC

CONSENT TO TREAT, PARTICIPATE & FULL LIABILITY WAIVER

Brands: The Recovery Room | The Recovery Room on Wheels
Clinician: Dr. Kelly Neumann, DPT, CIDN — Illinois PT License #070018951
NPI: 1942573415 | EIN: 99-2269313 | Insured by HPSO (Active Coverage)
Location: 1104 Bolin Ct, Springfield, IL 62703
Email: levelup@kinematicswithkelly.com | Phone: (217) 331-4700
Effective Date: January 2025 | Version: 1.0

1. NATURE OF SERVICES

Kinematics with Kelly, LLC (“KWK”) provides movement-based, performance, and wellness services under the direction of a Board-Licensed Doctor of Physical Therapy.

These services include, but are not limited to:

• HumanTrak and ForceDecks movement assessment

• Manual therapy and soft tissue interventions

• Integrative Dry Needling

• Cupping therapy

• Exercise instruction and performance education

• Recovery and mobility programming

• Workshops, wellness, and faith-based sessions

• Mobile and event-based Recovery Room services

These services are proactive, educational, and movement-based. They are not rehabilitation or insurance-driven physical therapy plans of care.

2. CLINICAL INTENT & DIAGNOSTIC DISCLAIMER

KWK provides movement analysis, not medical diagnosis.
Findings identify functional movement inefficiencies and performance asymmetries, not disease or pathology.

Services are delivered by a licensed Doctor of Physical Therapy, but do not establish a physician-prescribed rehabilitation plan or qualify as “medical necessity care” under insurance definitions.

If medical pathology or contraindications are suspected, KWK follows a strict Stop-and-Refer Protocol directing clients to appropriate medical providers.

3. CONSENT TO TREAT & PARTICIPATE

I voluntarily consent to receive services, education, and physical interaction (manual or movement-based) from KWK and its affiliates, including contractors, assistants, volunteers, and partner organizations.

I understand that:

• All services are elective and cash-based.

• My participation is voluntary and may be withdrawn at any time.

• I have the right to decline any exercise, modality, or treatment at my discretion.

• Sessions may include physical touch, manual techniques, and movement testing.

By signing below, I grant permission to Dr. Kelly Neumann, DPT, CIDN, and/or any KWK affiliate clinician to perform the agreed-upon services within their legal and ethical scope.

4. INTEGRATIVE DRY NEEDLING & MANUAL MODALITIES CONSENT

If Integrative Dry Needling (IDN), Cupping, or other manual modalities are used, I acknowledge that I have been informed of the nature, benefits, and potential risks.

Common Side Effects:

• Temporary soreness, bruising, or bleeding

• Mild fatigue or muscle ache

Rare Complications:

• Infection, nerve irritation, or pneumothorax (collapsed lung)

Mandatory Disclosures:

I agree to inform Dr. Kelly prior to treatment if any of the following apply:

• Current or suspected pregnancy

• Anticoagulant or blood-thinner use

• Bleeding or immune disorders

• Active infection or open wounds

• Implanted devices (pacemakers, spinal stimulators, etc.)

• Needle phobia or prior fainting (syncope)

KWK reserves the right to decline IDN or any modality for safety.

5. DATA COLLECTION, PRIVACY & EDUCATIONAL INTENT

I understand that KWK collects objective movement data through VALD ForceDecks and HumanTrak for performance education and clinical documentation.

• Data is stored in VALD Move Health, a HIPAA-aligned encrypted system.

• My data may be used for anonymized reporting or research under KWK’s evidence-based initiatives.

• I may request a copy of my data at any time.

• Data is educational, non-diagnostic, and does not replace medical testing.

6. MOBILE, OFFSITE & AFFILIATE SERVICES

KWK provides services both onsite and offsite through The Recovery Room on Wheels, affiliates, and partner organizations.

I acknowledge that:

• Mobile and event environments involve inherent risks (terrain, crowds, weather, equipment).

• KWK and its affiliates are not responsible for facility hazards or third-party conditions.

• Host organizations agree to provide a safe and suitable environment.

• Affiliates and contractors act as independent entities under KWK’s oversight, but not as employees.

7. ASSUMPTION OF RISK

I understand that participation in movement-based and manual services may involve inherent physical risks.
These may include:

• Soreness, strain, or fatigue

• Exacerbation of existing symptoms

• Environmental risks in mobile settings

I voluntarily assume all risks associated with participation in KWK services, whether provided by Dr. Kelly or any KWK affiliate.

8. WAIVER, RELEASE & INDEMNIFICATION

This is a binding legal release.

I hereby waive, release, and forever discharge Kinematics with Kelly, LLC; Dr. Kelly Neumann, DPT, CIDN; all affiliates, employees, contractors, assistants, volunteers, and host organizations from any and all claims, demands, or causes of action arising out of participation in services, including but not limited to ordinary negligence.

I further agree to indemnify and hold harmless KWK and its affiliates from any liability, loss, or damage resulting from:

• Failure to disclose medical information

• Ignoring clinical advice

• Unsafe or excessive participation

• Misuse of services or information

Liability for KWK and affiliates is limited to the total amount paid by the client in the three (3) months preceding the claim.

9. MEDIA, MARKETING & TESTIMONIAL RELEASE

I authorize KWK to use non-identifiable photos, videos, or de-identified performance data for documentation, education, or marketing unless revoked in writing.

10. GOVERNING LAW & VENUE

This Agreement shall be governed by and construed in accordance with the laws of the State of Illinois.
Venue for all disputes shall be Sangamon County, Illinois.

Dispute resolution shall follow:

1. Good-faith discussion

2. Mediation in Springfield, IL

3. Arbitration or litigation as required by law

 

“Kinematics with Kelly, LLC operates as a Doctor of Physical Therapy–led organization providing proactive, movement-based recovery and wellness services. All services are educational, non-diagnostic, and cash-based. Participation does not establish a medical Plan of Care or insurance-based rehabilitation. All data, affiliates, and mobile services comply with HIPAA, APTA, and Illinois Physical Therapy Practice Act regulations.”