Backstage Physical Therapy Consent Form

Dancer Name*

First NameLast Name

Dancer's Phone Number*

Please enter a valid phone number.

Dancer's Email*

example@example.com

Date of Birth*

Date

Today's Date*

Date

Dance Company/School*

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.

Name of person signing form*

Relationship to patient*

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

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.

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.

3. RELEASE OF INFORMATION

I hereby authorize the designated parties below to received protected health information regarding treatment or dance recommendations, 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

Would you like us to communicate with your dance company about specific dance modifications or PT recommendations?*

YesNo

If you wish us to communicate with other medical providers about our recommendations, please list them below

4. PHOTO RELEASE

We occasionally share 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 photos of you/your dancer in our media?*

YesNo

Signature*

Note URL

example@example.com