Wellness Consent and Waiver Form
Wellness care is a form of care that involves a dynamic process of making healthier lifestyle choices to enhance your physical, mental, and social attitudes, keeping you free of pain and illness.
Name
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First Name
Last Name
I hereby request and consent to the performance of wellness interventions on me or the client/patient name listed below for which I am legally responsible by Ascent Physical Therapy, PLLC and any of it’s associates (the “Practice”). If the client/patient is a minor, I represent that I am the parent or legal guardian of the child named below or I have obtained the required permission from the parent/legal guardian of the child named below to execute this agreement on their behalf.
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I AGREE
I understand that the Practice performs wellness services as well as Physical Therapy Services that is within its scope of practice declared by the New York State (NYS) Practice Act. I understand that my sessions with the Practice are not a substitute for adequate medical care, diagnosis and/or treatment from a medical doctor. If I am suffering from any medical condition outside of the scope of wellness or out of the scope of practice of Physical Therapy, I understand that I should see a licensed physician and under no circumstances should I forego any medical treatment recommended by a doctor.
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I AGREE
I understand that wellness involves the use of equipment, machines, physical exertion, movement, stretching, and other maneuvers involved to reach goals set upon as a team. I understand that necessary services will be determined through client assessment, which will be conducted during the initial session. I also understand that changes to my plans may occur and will be determined through further assessment in subsequent sessions.
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I AGREE
I understand that the Practice will do its best to ensure no harm to any client during the provision of intervention or use of any equipment. However, I further understand that therapy may result in unforeseen accidents or injury. I will notify my physical therapist immediately if anything happens that is painful or unusual.
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I AGREE
I understand that there are certain procedures that are inappropriate for women who are pregnant and that it is my responsibility to immediately tell the Practice if I become pregnant, so that proper precautions can be taken.
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I AGREE
I understand that there are certain treatment procedures that are inappropriate for anyone who has a pacemaker, which I do not currently have, and that it is my responsibility to immediately tell the Practice if my condition changes, so that proper precautions can be taken.
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I AGREE
I do have a pacemaker
I have provided all necessary medical, mental and physical information that is known to me at the time of signing this document. I understand it is my responsibility to update the Practice accordingly, in writing, of any changes to my medical, mental and/or physical condition. Should I not provide accurate information or fail to update the Practice of any changes in writing, I agree to release Robert Berghorn Jr., DPT, ATC, USAW, the Practice, its predecessors, parent, subsidiaries and affiliates, officers, and employees of any and all liability for any and all injuries, damages or claims.
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I AGREE
If a doctor’s permission is either necessary or requested by the Practice or any person associated with the Practice, before the start of the wellness program, I am fully responsible for obtaining such permission in writing and presenting it to the office prior to the start of treatment.
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I AGREE
I understand that the Practice will keep all communications and records confidential, unless I consent in writing to share this information with others. However, I consent to the Practice’s use and disclosure of my Protected Health Information (PHI) for the purpose of providing treatment to me, for the purposes relating to the payment of services rendered to me and for the office’s general healthcare operations purposes. PHI relates to any information created or received by the office, that relate to my past, present or future physical and mental health or condition, that either identifies me or where there is a reasonable basis to believe the information can be used to identify me.
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I AGREE
I acknowledge that I have read and understand the HIPAA privacy agreement provided to me by the Practice.
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I AGREE
While there have been no warranties, assurances, or guarantees made to me, I consent and freely agree to receive care from Ascent Physical Therapy, PLLC. I understand that while the Practice may make certain recommendations to me during the sessions, it is entirely my own decision whether or not to accept and follow these recommendations. I have read and understood the information provided in this Consent Form, as well as all materials provided to me. I have asked any and all questions that I may have about the sessions and these questions have been answered to my full satisfaction.
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I AGREE
I further agree to hold Ascent Physical Therapy, PLLC, the office and any associates or staff of the Practice harmless from any and all liabilities and claims, which may arise as a result of my participation in the sessions. I will not hold them responsible for any unforeseen injuries, the consequences of any decisions I may make, or any actions I may take, or may choose not to take, following any recommendation made by them.
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I AGREE
I also understand that there is a 24-hour cancellation policy and I am aware that I will be charged a cancellation fee of the entire cost of a session for a missed appointment if notice was not received within this time period. For any appointments that are scheduled on Monday, I understand that any cancellations will need to be made the Friday before, prior to 12pm. I understand that I may reschedule my session, without fee, by providing notice 12 hours in advance of the appointment. I further understand that payment is required at the time of service, but the practice will accept prepayments for future service.
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I AGREE
Please verify that you are human
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Signature - I represent that I am of sound mind and am legally competent to understand and complete this agreement. I hereby execute this consent form without coercion.
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