Consent For Treatment

I hereby give consent to Performance Driven Physical Therapy LLC to provide medical care and treatment as requested by myself, or my family member(s). I understand today’s services are not part of an established plan of care. They are not intended to fully treat or cure my condition, but rather serve as a recovery adjunct.

While Performance Driven Physical Therapy LLC fully intends to provide services that offer no harm, I understand there are inherent risks in receiving medical treatment and recovery adjuncts. I do not hold Performance Driven Physical Therapy LLC liable for any injury sustained.

I understand that Performance Driven Physical Therapy LLC is a hands-on Physical Therapy clinic. Though highly specialized, treatment consists primarily of manual therapy techniques and treatment forms that are published or otherwise publicly known. Forms of electrical stimulation, deep tissue massage, therapeutic exercise programs, neuromuscular re-education, Comprehensive Dry Needling, myofascial release, joint and soft tissue manipulation, as well as other treatment modalities may be used. Some of the hands-on treatment techniques require deep pressure or the use of needles which may cause bruising and periods of increased soreness which may last from 6-72 hours.

I understand that photographs and video may be taken for educational purposes. By signing below, I consent to the use of these photographs and videos in a private and professional manner.

Consent for Use and Disclosure of Health Information

I provide my consent to Performance Driven Physical Therapy LLC to use and disclose my protected health information to carry out treatment and additional health care operations.

I understand Performance Driven Physical Therapy LLC will maintain my privacy to the highest standards and may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided, and any administrative operations.

I acknowledge that I may request a copy of the Notices of Privacy Practices and Rights. Signing below indicates that I have refused a printed or electronic copy of these.