Wellness Intake Form

I hereby assert that the above information is accurate and best represents why I am seeking a wellness program. I understand that Flow Physical Therapy and Pilates will maintain my privacy to the best standard. I understand that my protected health information will only be used for the purposes of executing my care and wellness program, taking payment for services, and for any administrative functions pertaining to care and payment.

I do hereby give my consent for Flow Physical Therapy and Pilates to administer care that is appropriate and necessary for assessment and administration of a wellness program. I understand that there is no guarantee that the wellness program will resolve the issue for which I am seeking care.

I understand that a wellness program is not meant to address acute injuries or post-operative rehabilitation needs.

I understand that I may revoke my consent at any time by notifying the clinic in writing.

Cancellation Policy Consent

I understand that in the event that I need to cancel my scheduled appointment, I will provide at least 24 hours notice from the time of the appointment. Cancellations that occur within less than 24 hours of the appointment will result in a $50 fee to cover costs of doing business. A failure to attend the scheduled appointment without prior communication with the clinic will be considered a no show and will also incur the same $50 fee. The fee will be paid by me to Flow Physical Therapy and Pilates within 7 days of the occurrence.