I understand that I will receive education on my diagnosis, symptom pathology, exacerbating factors in addition to risks or alternatives to the treatment plan that has been prescribed by my practitioner. I also understand that my rehabilitation may require physical contact as the majority of my treatment is based on manual therapeutic approaches and can be sensitive in nature. Treatments could include Dry Needling and/or Spinal Manipulation, IASTM, Therapeutic cupping and other manual therapies. Treatments could include therapeutic exercise, neuromuscular reeducation, therapeutic activities and/or physical therapy modalities. Evaluative aspects may include various forms of technology such as musculoskeletal ultrasound (MSKUS), gait analysis, and/or Dorsavi testing for injury prevention. Verbal consent will also be received before performing these techniques. I understand that I have the right to refuse any treatment recommended by my practitioner and I agree to notify him/her if I feel uncomfortable in receiving or participating in any aspects of my care. I understand that I may experience postcare soreness and I agree to notify my practitioner should my symptoms last longer than 48 hours. By signing this agreement, I consent to have GO Physio provide treatment and care as set forth and verbally discussed through my plan of care.

GO Physio is fully HIPAA compliant to ensure patient confidentiality. This policy enables us to develop a trusting therapeutic relationship between practitoner and patient.

I_____________________, the undersigned, grant GO Physio permission to release information regarding my care to my personal physician and obtain medical records from my physician or other medical professionals as it relates to services provided by GO Physio. I understand that GO Physio will inform me prior to contacting any healthcare professional for information.

Payment for all services is due in full prior to services being rendered. GO Physio LLC is not enrolled as a participating Medicare provider nor is classified as a non-participating Medicare provider. Furthermore, GO Physio LLC does not contract with commercial insurance and is considered out-of-network. Our unique services blend various manual therapeutic techniques to facilitate physical rehabilitation and well-being combined with personal training and lifestyle guidance, and are not traditionally recognized by Medicare (and other third-party payors) as medically necessary. Thus, it is understood that the participating party is liable for any and all expense associated with services rendered by GO. In signing this form, you understand that GO Physio LLC has no obligation to bill your insurance on your behalf.

No refunds will be issued for any services rendered. We accept most forms of payments. Returned checks are subject to a $25.00 collection fee. Missed appointments or appointments cancelled less than 24 hours in advance are subject to a full treatment charge to mitigate for the loss of services that could have been provided to another patient during that time.

All subscription and/or membership-based services require 3-month commitment prior to cancelling your subscription. All subscription and/or membership-based enrollments are required to be cancelled by a member of the GO Physio team.