CONSENT FOR CARE & TREATMENT
I, the undersigned, do hereby agree and give my consent for Capitol Physical Therapy LLC to furnish medical care and treatment that is considered necessary and proper in diagnosing or treating my physical condition.


P.S: Please note that if for some reason you are having trouble filling this form, you can download a pdf copy of this form, print it out and fill offline at www.capitolptdc.com/new-patient-forms/

First Name *
Your answer
Last Name *
Your answer
Appointment Date *
This is not today's date but when you are seeing Dr. Nagasubramanian
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