Nicole Rodney Acupuncture

Nicole Rodney, PhD, LAc, MPH

Movement Medicine Participation Waiver & Informed Consent (Ohio)

Please fill out the following form.

Nature of Services

Movement Medicine is an integrative somatic movement approach rooted in East Asian medicine and modern somatic

principles. It incorporates guided movement, breathwork, postural awareness, and embodied attention to support regulation,

functional ease, and integration—particularly for individuals experiencing pain. These services are educational and

experiential in nature and are intended to complement acupuncture and integrative care.

Scope of Practice & No Medical Care

Movement Medicine is not physical therapy, rehabilitation, or medical treatment. The practitioner is not acting as a physical

therapist, personal trainer, or physician. No medical diagnosis, prescription, or guarantee of results is provided. Under Ohio

law, participants are responsible for seeking appropriate medical care for conditions requiring licensed medical treatment.

Voluntary Participation & Risks

Participation is voluntary. I agree to move within my own limits, modify or stop activities at any time, and inform the

practitioner of relevant conditions. I understand that risks may include temporary soreness, fatigue, dizziness, emotional

release, or flare-ups of existing symptoms, and I voluntarily assume all such risks.

Release of Liability

To the fullest extent permitted by Ohio law, I release and hold harmless Nicole Rodney Acupuncture and its practitioner from

any claims or liability arising from my participation, including those based on ordinary negligence.

No Emergency Care

No emergency medical services are provided. I am responsible for seeking emergency care if needed.

Consent

By initialing below, I acknowledge that I have read and understood this document and agree to participate under these terms.