Consent for Treatment

By receiving an in-clinic and/or in-home appointment and/or joining a phone and/or virtual (telerehab) appointment with _Straight to the Point Physical Therapy_, LLC:

• I agree that I am attending Straight to the Point Physical Therapy, LLC  to receive Physical Therapy assessment/treatment.
• I understand that __Straight to the Point Physical Therapy_, LLC will conduct an individualized assessment; which may include asking me questions and doing a physical and movement exam of the external muscular, vascular, and nervous systems. I am to report my symptoms, thoughts, and feelings with the assessment as this will guide the Physical Therapist. This can be stopped at any time.
• The Physical Therapist will explain their findings, discuss treatment goals, and explain all aspects of care, and I am to ask questions for clarification purposes when needed.
• I understand that I can stop the assessment/treatment at any time, and all aspects of Physical Therapist assessment/care are optional for me.
• I understand that all industry-standard privacy precautions are taken with my electronic information, but there may still be a risk to the anonymity of information.
• I understand that there are different safety risks associated with different types of Physical Therapy appointments and I release my Physical Therapist from any damages that occur due to treatment.
• I understand that there is a treatment fee payable at the end of my appointment time. Payment and receipts will be provided electronically.
• I understand that it is my responsibility to cover the cost of my appointment and that I am aware of the fact that Straight to the Point Physical Therapy, LLC is an out of network provider and that _Straight to the Point, LLC will not be submitting claims to my insurance.
• I am not currently covered by Medicare/Medicaid insurance and understand that Straight to the Point_, LLC is not enrolled as a Medicare provider and are out of network with ALL health plans.
• I understand that it is my responsibility to submit to my insurance should I wish to do so.
• Your Physical Therapist will verify you have read this document at the beginning of your appointment. They will discuss and answer any questions/concerns you may have.
• Print your name (first and last) below to acknowledge that you have fully read and understand the aforementioned consent statements, and consent to evaluation and treatment voluntarily.

• PROTECTING PERSONAL INFORMATION
  The privacy of your personal information is important to our clinic. We are committed to collecting, using, and disclosing personal information responsibly and only to the extent necessary for the goods and services we provide.
  Like all medical professionals, we collect, use, and disclose personal information in order to serve our patients. The primary purpose for collecting personal information is to provide treatment.
  Like most organizations, we also collect, use, and disclose information for purposes secondary to our primary purposes. The most common examples of our related and secondary purposes are to invoice patients for goods or services that were not paid for at the time, to process credit card payments, or to collect unpaid accounts.
  Like all medical professionals, personal information may need to be communicated/transmitted to another medical provider to ensure proper treatment and care is provided to you. Communication with your medical doctors / physicians, emergency medical technicians, and other medical providers may occur as necessary.

I understand that the clinic has taken reasonable steps to mitigate exposure of my personal information but that certain communication methods (email/text) with the clinic and physical therapist may be subject to inherent risks regarding privacy and/or confidentiality.

• Print your name (first and last) below to acknowledge that you have fully read and understand the aforementioned consent statements and are entering into them voluntarily.

• Print and sign below to acknowledge and consent that you fully understand the aforementioned consent statements and are entering into them voluntarily.

                                            ********LATE CANCELLATION OR NO SHOW POLICY********
Your appointment time is reserved just for you. Please be respectful of the therapist's time. If you need to cancel or reschedule your appointment, please call or email us at least 24 hours in advance. Cancellations or missed appointments within less than 24 hours' notice will result in a charge of 100% of the appointment fee. True emergency situations will be considered on a case-by-case basis.

• Print your name (first and last) below to acknowledge that you have fully read and understand the aforementioned consent statements, and are entering into them voluntarily.

• I hereby consent to the aforementioned statements.

• I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS.  I AM AWARE THAT THIS IS A RELEASE AND WAIVER OF LIABILITY AND SIGN IT KNOWING, VOLUNTARILY, AND OF MY OWN FREE WILL.  
  My signature below constitutes my acknowledgement that (1) I have read, understand, and fully agree to the foregoing consent, (2) the proposed recovery process has been satisfactorily explained to me and I have all the information I desire, and (3) I hereby give my authorization and consent.  This consent shall stand as long as I use the equipment now and in the future.    My signature also gives _Straight to the Point Phyhsical Therapy, LLC permission to use my photos in any social media post or marketing.
•           I have read the instructions for proper use of the facilities and do so at my own risk and hereby release the owners, operators, franchisers, or manufacturers from any damage or harm that I might incur due to use of the facilities. In signing this release, I acknowledge and represent that I have read and understand the foregoing Waiver of Liability and Hold Harmless Agreement, I am at least eighteen (18) years of age and fully competent (or for under 18 have parent/guardian consent), and I execute this Release for full, adequate, and complete consideration fully intending to be bound by same. I agree that I will comply with all instructions on the use of the recovery devices and that I am using these services at my own risk.  I agree to use all sessions within the terms of the contract dates and understand that refunds are not given on unused portions of purchased packages.
• Print your name (first and last) below to acknowledge that you have fully read and understand the aforementioned consent statements and are entering into them voluntarily. 

• Sign and Date
• (print)
• (sign)
• (date)