Physical Therapy Intake

I hereby assert that the above information is accurate and best represents why I am seeking physical therapy. 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 medical care and treatment, taking payment for services, and for any administrative functions pertaining to treatment and payment.

I do hereby give my consent for Flow Physical Therapy and Pilates to administer care that is appropriate and necessary for the evaluation and treatment of the diagnosis or physical condition. I understand that there is no guarantee that physical therapy will resolve the issue for which I am seeking treatment.

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

I understand that by checking the box to agree to the above statements, I am authorizing this as my signature.

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. The late fee will be paid to me within 7 days of the occurrence.