Physical Therapy Treatment Agreement and Consent Form

Patient Information

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

1. Consent to Treatment

I, the undersigned, give consent to receive physical therapy evaluation and treatment from [CLINIC NAME] and its licensed physical therapists and staff. I understand that physical therapy may include:

• Manual therapy techniques
• Therapeutic exercises
• Physical agents and modalities
• Functional training
• Home exercise instruction

2. Financial Agreement

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

3. Rights and Responsibilities

Patient Rights:

• Receive quality care regardless of race, gender, or beliefs
• Be informed about treatment plans and alternatives
• Refuse treatment at any time
• Privacy and confidentiality of medical information

Patient Responsibilities:

• Provide accurate medical history
• Follow prescribed treatment plan
• Attend scheduled appointments
• Inform therapist of changes in condition

4. Acknowledgment of Risks

I understand that physical therapy involves certain risks, including but not limited to:

• Temporary soreness
• Potential for aggravation of symptoms
• Rare possibility of injury

5. HIPAA Acknowledgment

I acknowledge receipt of the Notice of Privacy Practices and consent to use and disclosure of protected health information for treatment, payment, and healthcare operations.

Signature: _________________________ Date: _____________ PT Signature: ______________________ Date: _____________

[Clinic Name and Contact Information]