Occupational Therapy Services Agreement and Consent to Treat

Patient Information

Name: _________________________ Date of Birth: _____________ Address: _______________________ Phone: ___________________

Agreement Terms

1. Consent for Treatment

I, _________________________, consent to occupational therapy evaluation and treatment provided by [Practice Name]. I understand that occupational therapy may include:

• Assessment of daily living activities
• Physical rehabilitation exercises
• Cognitive and perceptual training
• Adaptive equipment training
• Therapeutic activities

2. Financial Responsibility

• I understand that I am responsible for all charges not covered by insurance
• Co-payments are due at the time of service
• Cancellation fee may apply with less than 24-hour notice

3. Release of Information

I authorize [Practice Name] to:

• Release medical information to insurance carriers
• Share relevant information with other healthcare providers
• Document treatment through photos/videos (separate consent required)

4. Treatment Understanding

I acknowledge that:

• No guarantees have been made regarding treatment outcomes
• Active participation is required for optimal results
• I have the right to refuse any aspect of treatment
• I will inform the therapist of any changes in my medical condition

5. Safety and Equipment

I agree to:

• Follow all safety instructions provided by the therapist
• Use adaptive equipment as recommended
• Report any equipment malfunction or concerns

Signatures

Patient/Guardian: _________________ Date: _____________

Occupational Therapist: ____________ Date: _____________

Witness: ________________________ Date: _____________