REGISTRATION FORM

Physical Therapy Consent Form

I hereby authorize PATH PT LLC and/or such assistants to provide physical therapy services. I acknowledge that the purpose of physical therapy is to diagnose and treat disease, injury and disability by use of rehabilitative procedures, mobilization, massage, exercises, and physical agents to aid in achieving maximum potential, accelerating recovery and reducing the length of functional impairment. I understand that all procedures will be thoroughly explained to me before I am asked to perform them.

I accept the treatment recommendation of my physical therapist. I acknowledge that no warranty or guarantee has been made as to the results of this therapy. I understand that any aspect of this consent form that I do not understand will be explained to me in further detail by asking my physical therapist. It is my right to ask my physical therapist about the treatment plan based on my individual history, physical therapy diagnosis, symptoms, and examination results. I further certify that my physical therapist has informed me of the nature and character of the proposed treatment, of the anticipated result, alternative treatment choices, and the possible risks, complications, and anticipated benefits involved in the proposed therapy.

I understand that PATH PT LLC 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.

Photographs/Videos may be taken during initial evaluation, progress evaluation and discharge summary as they will be used for postural comparison purposes and as educational tools. If preferred, the face can be blurred out if media files are posted on a social media platform upon request. Opting out is permissible upon request. If media files are shared on social media platforms for comparison or educational purposes, patient health data will be displayed in a non identifying manner. By signing below I consent to the use of these photographs/videos in a professional manner.

I understand that I retain the right to revoke this consent by notifying the practice in writing at any time.

I have read this consent form and understand the risks involved in physical therapy and agree to fully cooperate, participate in all physical therapy procedures, and comply with the established plan of care. The therapy as stated, including the possible risks, complications, options, and expectations have been explained to me, my representative or legal guardian (if minor).

Liability Waiver

The Client acknowledges that participation in physical therapy/fitness sessions involves a level of risk, and the Client assumes full responsibility for any injuries or damages that may occur during or as a result of participating in these sessions. The Client releases the Provider from any liability for injuries or damages.

By entering your contract information, you are agreeing that you have read, understand, and accept the liability waiver & consent forms. You understand the risks involved in the services listed above and agree to fully cooperate and participate in all procedures, and comply with the established plan of care. 

Communications

I hereby give consent to PATH PT LLC to utilize the contact information I provide for promotion and free information about health-related topics.