2022 HIPAA/Informed Consent Form

HIPAA/Informed Consent Form
Patient Name *

First Name Last Name
Today's Date *

Month Day Year
Date
Please choose one: *

I am the patient, am over 18, and am completing the form myself. The patient is a minor and this form is being completed by a parent/guardian.
This form is being signed by *
Relationship to patient *
1. INFORMED CONSENT TO PHYSICAL THERAPY EVALUATION AND TREATMENT

I hereby consent to evaluation and/or treatment of my condition by a licensed physical therapist employed by Carolina Dancer Wellness. The physical therapist has fully explained to me the nature and purposes of the procedures, evaluation and course of treatment. The physical therapist has informed me of expected benefits and possible complications or discomfort, which may result from skilled physical therapy care. In addition, the physical therapist has explained to me the risks of receiving no treatment.

The physical therapist has explained that there is no guarantee that the proposed course of treatment will improve my condition and that is possible, although unlikely, that the course of treatment may cause additional pain or discomfort or aggravate my condition. The term “informed consent” means that the potential risks, benefits, and alternatives of physical therapy treatment have been explained to me. The therapist provides a wide range of services and I understand that I will receive information at the initial visit concerning the treatment and options available for my condition.

I have been given on opportunity to ask questions, and all my questions have been answered to my satisfaction. I confirm that I have read and fully understand this consent form. In the event of a change in medical status, I understand that my treatment may be modified, stopped, or referred out to the proper practitioner. I reserve the right to withdraw at any time.
Signature *

Clear
2. PATIENT INFORMATION CONSENT FORM (HIPAA)

The patient understands that: Protected health information may be disclosed or used for treatment, payment, or health care operations. The Practice has Notice of Privacy Practices and that the patient has the opportunity to review this Notice. The practice reserves the right to change the Notice of Privacy Practices. The patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions. The patient may revoke this Consent in writing at any time and all future disclosures will then cease. The Practice may condition receipt of treatment upon the execution of this Consent.
Signature *

Clear
3. Electronic Communication (Text and Email)

Many patients prefer to communicate via text and email for appointment reminders, billing statements, and for general questions about their treatment programs. Please note that this form of electronic communication is never absolutely secure texts, emails, and billings statements may contain health information.
Do you consent to receiving electronic communication (texts and emails) from our office? *

Yes No
4. RELEASE OF INFORMATION

I hereby authorize the designated parties below to received protected health information regarding treatment or administrative operations related to my course of treatment.

Parents/Guardians of minors do not have to be listed below to receive information about their child. Please include doctors offices and other providers that you would like us to share information with.
Please list the names and relationship to the patient of individuals with whom you wish us to share information.
Do you want us to communicate with your studio/company about your injury/PT? *

Yes No
Please indicate the name of the studio and/or individuals you would like to share information with. *
5. Photo Release

In 2022 we will be sharing images of dancers who are examples of good technique and making progress towards goals to help encourage and educate other dancers. Options are available to be included on our social media (website, Facebook and Instagram), as part of home exercise programs, or educational programs.
May we include you/your dancer in our media? *

Yes (Individual selections are available on next page) No

Please use the button below to complete your form.

Photo Release Form
By consenting to the release of images to Carolina Dancer Wellness, I understand that:

Images may be used in educational materials, social media (Facebook, Instagram, website, etc), and online and printed marketing materials.
No compensation is expected, in cash or in kind.
Subject's names will not be included in the images for exercise demonstration. Names may occasionally be included for website, Facebook, and Instagram posts, but only if permission is given below.
Your consent or refusal to consent to the release of your photographs will not, in any way affect the services you receive from our company.
You may rescind your authorization to the release of the photographs by submitting a request in writing.

I hereby grant the Carolina Dancer Wellness and its agents permission to use photographs, digital images of me, or in which I may be included in whole or part, for the purposes indicated below.
I authorize the use of photographs for the following: *

Educational purposes such as exercise handouts, videos, presentations, etc Social media (website, Instagram, Facebook) Print marketing materials
Please indicate your preference *

My name may be included for website, Facebook, and Instagram posts, etc Please do not include my name with any photos
Signature *

Clear
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HIPAA/Informed Consent Form

Photo Release Form