Telehealth Waiver Form
Date of Birth
Physical Therapy Clinic Email ( Iptcrete@att.net )
Patient's Phone Number
Street Address Line 2
State / Province
Postal / Zip Code
Waiver / Consent
I authorize Independence Physical Therapy to perform telehealth services for assessing and diagnosing my medical condition using telecommunications programs.
I confirm that medical professionals can reach me with video calls or audio calls as part of the online sessions.
I understand non-medical associates of Independence Physical Therapy my be present during session for training, technological support and general staffing.
I acknowledge that in this type of platform technical difficulties may happen which might cause a slight delay or might need rescheduling.
I accept that I can withdraw this waiver any time and it will not affect my situation when I needed care in the future.
I understand that it is my responsibility to provide all necessary information like signs and symptoms, medical history, current condition to the health professional.
I confirm that telehealth services require the collection of personal medical data to the health professional remotely which means they are based on any area.
I confirm that the information I provided here will not be shared with others without my consent.
I confirm that all information I provided in this online session is accurate and true.
Should be Empty: