Physical Therapy Studio
Consent to treat
I understand that Physical Therapy Studio will maintain my privacy to the highest standards and may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment. I have read the Privacy Policy
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Photographs taken during initial evaluation, progress evaluation and discharge summary will be used for postural comparison purposes and as educational tools. By signing below I consent to the use of these photographs in a professional manner.
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I do hereby agree and give my consent for Physical Therapy Studio to furnish care and treatment that is considered necessary and proper in the diagnosing or treating of my physical condition.I understand that I retain the right to revoke this consent at any time
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I understand that recommendations will be made by my therapist, based on the findings in this session, for improvement of my pain and overall wellness. I understand that I may be directed through specific activities, exercises and/ or movements as instructed by my therapist. I am aware that my physical therapist will inform me of expected benefits and complications, and any discomforts, and risk that may arise, as well as alternatives to the proposed treatment and the risk and consequences of no treatment.
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I have been informed and understand that during my participation in any sessions, I will be responsible for honestly reporting any symptoms I may have, such as pain, fatigue, shortness of breath, pain or ANY other findings.
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I know that it is my right to stop any activity at any time, during any session, as well as it being my obligation to inform the therapist of any symptoms, should any develop (as indicated above
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I recognize that these sessions will allow me to learn ways to move better, feel better and teach me techniques and skills that I can utilize independently on a daily basis and improve my quality of life.
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I am aware that addressing my symptoms or diagnosis may take a few sessions and I am required to closely follow all provided instruction to ensure improvements within at least 6-8 sessions (if not sooner).
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I understand that the number of sessions will vary based on the primary complaints and symptoms and that this reference serves as an average and not a definite number.
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I understand that I am 100% responsible for payment, due at time of scheduling. NO insurance in any form will be billed, charged or collected for these sessions. I choose by my own free will to participate and invest in this service.
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I hereby consent to the evaluation and treatment of my condition by a licensed physical therapist (Caren Lieberman PT 14854). I understand that the physical therapist will explain the nature and purposes of these procedures, evaluation, and course of treatment.
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I understand that my therapist will make every effort to address my symptoms, functional deficits (if any) and concerns and that the goal is for total alleviation of symptoms and/ or improvement of function. Even with the best program there is a possibility that I may not notice changes or improvements.
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I hereby consent to receive texts(automated and live) and voice mail at mobile number documented.
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I hereby consent to receiveemails form Physical therapy Studio
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I hereby certify that all the above information is true to the best of my knowledge.
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