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.

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Indicated below are individuals whom Capitol Physical Therapy LLC may speak to regarding my treatment. Please list names and their phone numbers. (one person per line) *
For e.g John Doe - (202)-555-5555
Listed below are individual(s) whom I request restriction regarding my protected health information. Please list names (one person per line).
We may need to contact you. Do we have your permission to leave a confidential message at the phone numbers you have provided us? *
First Name *
Your First Name
Last Name *
Your Last Name
Today's Date *
Emergency Contact Name *
Emergency Contact Phone Number *
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