Consent for Physical Therapy Evaluation and Treatment

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

*Please note, this is a HIPAA compliant form. Your information is protected.

By checking the boxes below, and completing and submitting this form you agree to receive physical therapy examination and treatment. A printed copy is available upon request.

Included in the terms and conditions are Bonner Physical Therapy's policies regarding the COVID 19 Pandemic, available here: https://www.bonnerphysicaltherapy.com/schedule-a-physical-therapy-appointment

I hereby grant my authorization and consent to such examination(s), treatment(s) as deemed necessary by the medical providers at this office.

I understand if I have questions or need further explanation on an examination technique or a treatment approach that I should always ask my treating medical provider for a more detailed explanation.

Required

First and Last Name: *

Date *

YYYY

Clear form

Never submit passwords through Google Forms.

Forms

This form was created inside of bonnerphysicaltherapy.com.