Physical Therapy Informed Consent Form

Patient Information

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

Consent for Treatment

I, _________________________, hereby consent to receive physical therapy services from [CLINIC NAME]. I understand that physical therapy may include:

• Manual therapy techniques
• Therapeutic exercises
• Physical agents and modalities (heat, cold, electrical stimulation)
• Mechanical traction
• Therapeutic activities
• Functional training

Risks and Benefits

Potential Benefits:

• Pain reduction
• Improved mobility and function
• Enhanced strength and flexibility
• Better balance and coordination

Potential Risks:

• Temporary soreness or pain
• Skin irritation
• Temporary increase in symptoms
• Dizziness or lightheadedness

Financial Agreement

I understand that I am responsible for:

• Payment of all services rendered
• Verifying insurance coverage
• Any copayments or deductibles
• Charges not covered by insurance

Privacy Notice Acknowledgment

I acknowledge receipt of the Notice of Privacy Practices (HIPAA).

Right to Refuse Treatment

I understand that I have the right to:

• Ask questions about my treatment
• Decline any procedure
• Stop treatment at any time

Signatures

Patient/Guardian Signature: _________________ Date: _________ Physical Therapist Signature: _______________ Date: _________

Witness

Witness Signature: _________________________ Date: _________