TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended diagnostic, physical therapy or rehabilitation treatment/procedure to be used so that you may make the decision whether or not to undergo the treatment/procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you may give or withhold your consent to the treatment/procedure.
I (we) voluntarily request Delta Physical Therapy and Sports Medicine, PC and dba Fillmore Physical Therapy, its physical therapists, and such associates, technical assistants and other health care providers as they may deem necessary, do an evaluation, or give advice or with proper referrals to treat my condition which has been explained to me. I (we) understand that the following physical therapy or rehabilitation evaluation, advice or treatment / procedures are planned for me and I (we) voluntarily consent and authorize these procedures. I (we) understand that my physical therapist may discover other or different conditions which require additional or different procedures than those planned and may require consent from my physician before such additional or different procedures are utilized. I (we) authorize my physical therapist, and such associates, technical assistants and other health care providers with consent from my physician to perform such other procedures which are advisable in their professional judgment.
I (we) understand that no warranty or guarantee has been made to me as to result or cure.
Just as there may be risks and hazards in continuing my present condition without treatment, there are also risks and hazards related to the performance of the diagnostic, physical therapy, or rehabilitation treatment / procedures planned for me. I (we) realize that common to diagnostic, physical therapy, or rehabilitation treatment/ procedures is the potential risk for such procedures and treatment to cause side effects, pain, or other problems.
I certify that the information I have provided is complete and true to the best of my knowledge.
I give my authorization for treatment records to be released to the responsible payor for reimbursement consideration, or medical facility necessary for treatment or further care. Additionally, I request that any medical records requested by this facility, necessary for treatment or further care, be forwarded to this facility upon its request.
I understand that I am financially responsible for all charges whether or not paid for by said insurance (i.e. deductible amounts, co-insurance, co-pay, medical necessity, or any other balance not paid by my insurance). If this account is assigned to an attorney for collection and/or suit, the facility shall be entitled to reasonable attorney’s fees and costs of collection.
I request that payment of authorized benefits be made on my behalf to this facility. I assign the benefits payable to which I am entitled to this facility for services rendered. This assignment will remain in effect until revoked by me in writing. A photocopy and/or facsimile of this assignment is to be considered as valid as an original.
I have received a copy of the Notice of Privacy Practices for Delta Physical therapy and Sports Medicine, PC, and dba Fillmore Physical Therapy. Delta Physical Therapy and Sports Medicine, PC reserves the right to modify the privacy practices outlined in the notice.
I have read the foregoing and I understand it. Any questions that have arisen or occurred to me have been answered to my satisfaction.
COMPLETE IF OVER THE AGE OF 18 YEARS OF AGE:
The undersigned, being over the age of eighteen (18) years and being under no disability or prohibition that would in any way prevent or affect the Consent and Release, does hereby represent that,
I(CLIENT), consent to an evaluation, advice or rehabilitation treatment as prescribed by my provider and agree to pay for all services received.
COMPLETE IF THE CLIENT IS A MINOR OR WHEN THE ADULT CLIENT IS NOT COMPETENT:
In the treatment of (MINOR/ADULT CLIENT), I , client representative of said minor/adult, consent to an evaluation, advice or rehabilitation treatment as prescribed by minor’s/adult’s provider . My relationship to the client is (i.e parent, son, daughter, etc) .
Signature of Parent/Legal Guardian
FINANCIALLY RESPONSIBLE PARTY: I agree to pay for all services received.
Printed Name of Financially Responsible Party , Phone , SSN
Employer Name , Phone
Responsible Party’s Signature
● It is imperative that you are on time for appointments. You can expect the same from US!
● If you must cancel or reschedule an appointment, we require proper notice (at least 24 business hours).
● If you fail to provide proper notice, your Therapist will discuss with you alternative scheduling options.
● We treat pain! If you are experiencing pain and are thinking about cancelling, please call to discuss with your Physical Therapist.
● We HATE having to enforce rules, but in order to provide the level of care that we are known for and you deserve, we have to be consistent with everyone.
● If you have difficulty keeping scheduled appointments and would like to continue to schedule weekly, you may do so by reserving your visit with a $100 deposit on file.
Office Staff Initials
Patient Name: Preferred Name:
Patient Address: City State Zip
Patient DOB: Patient SS#
Employer: Employer phone number:
Name on Insurance Card: DOB of Primary Insured:
Secondary name on card: DOB
1. Have you received any home health services or help in the home in the last three months?
NOYES (please STOP and let office staff know why)
2. Why are you seeking Physical Therapy Services? When did the problem begin?
3. Have you ever been injured or suffered previous pains/problems in this area?
NOYES If yes, when?
4. Regarding why you are coming to Physical Therapy have you:
Had a recent X-RayCTMRINerve Test (EMG/NCV)N/A
If YES, When? Where?
Received any other treatment like: Physical TherapyChiropracticMassagePersonal TrainingAthletic TrainingInjectionsHome HealthN/A
If YES, When? Where?
5. Have you had 2 or more falls in the past year, OR any fall with injury in the past year?
6. Female Clients: Are you pregnant?NOYESUNSURE
7. Medications: including prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary nutritional
NONESee Medication List provided by patient
ROUTE OF ADMINISTRATION
( oral, sublingual, subcutaneous,
injections, topical, etc.)
8. Surgeries:NONESee surgery list provided by patient
9. Do you have OR have you had any of the following?
Breathless at rest or after mild exertionBowel and bladder problemsUnexplained weight loss or gainAnemiaThyroid ProblemsBlood ClotMultiple SclerosisHerniaChest painPacemakerIrregular HeartbeatHigh blood pressureNight sweatsPain at nightHeadachesDizzinessFaintingVision difficultiesSpeech difficultiesHIV/hepatitisAlzheimer’sDementiaStrokeHistory of CancerOsteoarthritis/osteoporosisParkinson’sRheumatoid ArthritisSeizures/ConvulsionsDiabetes Type 1NONE OF THE ABOVE
Diabetes Type 2 Diabetes: Have you had your foot measured recently or do you need to see a podiatrist for diabetic footwear?
Notes for your Physical Therapist:
WHO CAN WE SHARE YOUR MEDICAL INFO WITH (PRIVACY ACT)
1. Patient’s Printed Name:
Last First Initial or Other
2. DELTA PHYSICAL THERAPY AND SPORTS MEDICINE, PC will only disclose the protected health information you permit related to photographs, videos, and or testimonials (PHI)
Check the boxes listed below to which you agree and acknowledge understanding of:
Photographs that identify meVideos that identify meTestimonials that I have voluntarily made and given to DELTA PHYSICAL THERAPY AND SPORTS MEDICINE, PC or one of its employees
Check as many items as you agree to:
The items I have checked above may be used for any ethical and moral purpose in blogs and other social media
The items I have checked may be used for:
MarketingProfessional educationGeneral consumer education
I have been informed that I can revoke this consent at any time and DELTA PHYSICAL THERAPY AND SPORTS MEDICINE, PC will discontinue further use or disclosure at that timeI realize that if any information has been posted on the internet DELTA PHYSICAL THERAPY AND SPORTS MEDICINE, PC cannot control how my photographs, videos or testimonials are used by othersI realize that the above items cannot be restricted from use/disclosure for treatment, payment or operations
3. Check ONLY one box indicating how long DELTA PHYSICAL THERAPY AND SPORTS MEDICINE, PC can use this consent:
Disclose my information indefinitely (as long as DELTA PHYSICAL THERAPY AND SPORTS MEDICINE, PC has custody of my files)
* Disclose my PHI for the period beginning and ending
Signature of Patient
Signature of Parent or authorized Representative (Indicate the Relationship)
You can refuse to sign this consent
Patient Name: Email:
Home Phone: Cell Phone:
I authorize Delta/Fillmore Physical Therapy and Sports Medicine, PC, to send Appointment Reminders electronically via Phone Call, Text, or Email. I understand that this service is offered free of charge. However, standard text messaging rates from my mobile carrier may apply if text message is chosen.
Please sign me up for 24 hour Appointment Reminders via:
EmailHome PhoneCell Phone
Studies show that following a home exercise program shortens recovery time. Our office uses WebExercisesⓇ to help you at home. You can easily access WebExercisesⓇ with your regular email and you will not receive unsolicited email from us or WebExercisesⓇ. Regular email is not protected by a security process called encryption so please understand there is some level of risk that information in any regular email can be read by someone besides you.
In order to get access to WebExercisesⓇ through your regular email, please check box 1 and provide your email address. If you only want to receive exercise handouts check box 2.
Please sign and date this form.
Yes. I prefer to participate in WebExercisesⓇ online program using my regular email. Please use the following email address:
**I will let you know right away if my email address changes.
I prefer to receive exercise handouts only.