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Informed Consent

Thank you for consulting with us. Please read the following information carefully before signing. You have the right to ask questions or decline any part of treatment at any time.

Physical Therapy Informed Consent

What is Physical Therapy?

Physical therapy is a rehabilitation method that helps patients gain or regain physical activities they lost or are incapable of doing due to defects either from birth or resulting from injuries or disease. There are various methods of treatment to help one regain and/or improve physical function.

How Physical Therapy is Done

Physical therapy is often done with the help of guided exercises. Some use additional agents such as heat or cold compress, sound waves, electricity, or mechanical devices or machines. This will depend on the issues that need to be addressed and the technology available for the physical therapist to utilize.

The Risks

As physical therapy intends to resolve the problem the person is experiencing due to illness or injury, there are some risks that may arise during the course of treatment such as pain and discomfort during the process of therapy. Stretching and twisting may cause some swelling and soreness of stiff muscles. This is normal. There are therapies that may use hot or cold compresses in order to relieve pain during therapy. Your physician may prescribe drugs to help with pain and swelling while going through the process of physical therapy. Please note that some can experience pain and discomfort that may reduce motivation to continue. It is important that the person continues with the therapy if it is too early to conclude the results. It would be best to discuss these matters with your physical therapist.

Expectations

There are no guaranteed expectations when one undergoes physical therapy treatment. This depends on the situation. But when one undergoes a physical therapy program, it is intended that one will be able to return to his or her prior level of functioning or develop a method to continue what was possible before the injury. When going through the program, it is important that the patient is truthful with what he or she thinks or feels. Proper communication is important for the progress of the patient.

Fees and Schedule

One session is approximately 1 hour and each session is by appointment. Call or text (623) 696-6550 to schedule an appointment. A physical therapy evaluation is $170. Follow-up visits are $130 per session for visits 1–7, or $120 per visit when you bundle 8 or more visits. Therapeutic exercise is $80 for 45 minutes and massage therapy is $100 for 45 minutes — no evaluation required for flat-fee services. Payment is required at time of service. If you wish to submit for out-of-network reimbursement, a superbill will be provided free of charge. A distance surcharge may apply for visits located 20 or more miles from Goodyear, AZ. HSA/FSA accepted.

Cancellation Policy

Please provide 24-hour notice if you wish to cancel your appointment. Because we schedule one hour plus travel time, cancellations can have a significant impact on other patients' ability to get an appointment. A cancellation fee of $100 will be charged for any appointment cancelled without 24-hour notice.

Confidentiality

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), we are required to keep all medical information of every individual securely and shall not disclose it to anyone without authorization. This allows the patient to have the right to determine how his or her information is used. The records we acquire from you shall be used for managing health care by health care providers and will be used for reference for payment or reimbursement for services such as billing or collection. We may also use your information for the assessment and improvement of our activities and business operations.

Patient Information

First Name *

Last Name *

Email *

Phone *

Consent & Signature

I have read all the information provided here or it has been read to me. I understand the contents of this informed consent form. I understand the risks involved in physical therapy and agree to participate in the procedures to be conducted and comply with the established plan of care set forth by my physical therapist. I have had the opportunity to ask questions and all of which were answered to me accordingly. I am of legal age and I give my full consent to the physical therapy treatment.

Signature *

Draw your signature here

Date *

Your information is kept strictly confidential in accordance with HIPAA.