Physical Therapy Telehealth Informed Consent Form

Patient Information

Name: _________________________ Date of Birth: _________________ Address: _______________________ Phone: _______________________

Consent for Telehealth Services

Nature of Telehealth

I understand that telehealth physical therapy involves the delivery of healthcare services using electronic communications, information technology, or other means between a physical therapist and a patient who are not in the same physical location.

Benefits & Risks

Benefits include:

• Improved access to physical therapy care
• Convenience of home-based treatment
• Reduced travel time and costs

Potential risks include:

• Technical difficulties affecting service quality
• Limited physical contact for hands-on assessment
• Possible need for in-person visits if virtual care is insufficient

Patient Responsibilities

I agree to:

1. Be in a private, well-lit location during sessions
2. Wear appropriate clothing for exercise
3. Have adequate space for prescribed movements
4. Ensure reliable internet connection
5. Have necessary equipment as specified by the therapist

Emergency Procedures

Emergency Contact Name: _________________ Phone: ________________ Local Emergency Services Phone: _______________

Privacy & Security

I understand that:

• Standard privacy protocols apply to telehealth services
• Sessions will not be recorded without separate consent
• Electronic systems used will incorporate network and software security

Authorization

I have read and understand the information provided above regarding telehealth physical therapy services. I hereby give my informed consent to participate in telehealth physical therapy sessions.

Patient Signature: _________________ Date: _________________ Therapist Signature: _______________ Date: _________________