New Patient Paperwork (Cash)

Informed Consent
I do hereby agree and give my consent for Physical Therapy San Pedro to furnish care and treatment that is considered necessary and proper in diagnosing or treating my physical condition.

I understand that I retain the right to revoke this consent by notifying the practice in writing at any time.

I hereby certify that all the above information is true to the best of my knowledge.
Printed Name*
Signature*

Clear
Date*

MonthDayYear
Date
I understand that Physical Therapy San Pedro 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 related to treatment or payment.

Photographs taken during the duration of treatment will be used for postural comparison purposes and as educational tools. By signing below, I consent to the use of these photographs in a professional manner.
Printed Name
Signature

Clear
Date

MonthDayYear
Date
In addition, photographs and video will be used as educational tools for website and social media purposes. By signing below, I consent to the use of these photographs in this manner.
Printed Name
Signature

Clear
Date

MonthDayYear
Date

Cancellation/No-Show Policy

(Cash Pay)
At the time you book your initial appointment you will be required to put a credit card on file.

All cancellations need to be made 24 hours prior to your scheduled appointment.

If you do not show up for your appointment or cancel within 24 hours, your card on file will be charged for 100% of the session price.

You will be notified prior to the charge being applied.

To avoid this cancellation fee, you will also be offered a Telehealth appointment.
Telehealth Email*
example@example.com
Payment Policy

Your initial evaluation is $195 and follow up treatment sessions are $155. Payment, in the form of cash, check or credit card, is due at the time of each visit.

We are not billing your insurance company. However, the payments you make may be reimbursable by your insurance company under your out of network physical therapy benefits; the exact percentage depends upon your plan. Due to the complex nature of insurance claims and reimbursement, we make no promises as to whether you will receive reimbursement.

We will assist you in every way possible. Payment is due at the time of service.

I have read and understand the above policies:
Patient Name*
Patient/Guardian Signature*

Clear
Guardian Name*
Date*

MonthDayYear
Date
Thank you for your cooperation and business.

Patient Consent for Telehealth Services
First Name*
MI*
Last Name*
DOB*

MonthDayYear
Date
Age*
Today's Date*

MonthDayYear
Date
CONSENT FOR TELEHEALTH SERVICES (Initial Below)
I understand that I will be engaging in Telehealth with Physical Therapy San Pedro for my therapy evaluation and/or treatment sessions.*
Initials Here
It has been explained to me how the video conference technology will be used to conduct my physical therapy session and that there will not be direct patient/physical therapist contact due to the fact that I will not be in the same room as my physical therapist.*
Initials Here
I understand that there are potential limitations using this technology, including interruption, unauthorized access and technical difficulties. I understand that my physical therapist and/or I can discontinue the Telehealth session if it is felt that the videoconferencing connection is not adequate for the situation. *
Initials Here
I understand that my healthcare information may be shared with other Physical Therapy San Pedro staff for scheduling and billing purposes. The above-mentioned staff will maintain HIPAA confidentiality. *
Initials Here
The alternatives to a Telehealth session have been explained to me, and in choosing to participate in Telehealth session, I understand that some parts of the exam/therapy visit involving physical test/activities/ exercises may require the assistance of a caregiver/family member/ friend at my location at the direction of my physical therapist to conduct and /or gaurd me as the patient to ensure my safety. *
Initials Here
I understand that Physical Therapy San Pedro and my physical therapist responsibility of me, the patient, for a given session will conclude upon the termination of the video conference connection. *
Initials Here
I understand that Physical Therapy San Pedro will bill my session as usual to my insurance provider(s) as a physical therapy visit with the addition of using modifier codes to indicate my session was performed virtually using video conferencing technology.*
Initials Here
I have had a direct conversation with Physical Therapy San Pedro staff and /or my physical therapist, during which I had the opportunity to ask questions in regard to my physical therapy. My questions have been answered and the risks, benefits, and any practical alternatives have been discussed with me in a language in which I understand. *
Initials Here

I, THE PATIENT OR RESPONSIBLE PARTY OF THE PATIENT, HAVE READ, UNDERSTAND, AND AGREE TO THE STATEMENTS CONTAINED HEREIN: (Initial Below)
I acknowledge I have been given ample opportunity to ask questions and that any questions been answered to my satisfaction.*
Initial Here
I acknowledge I fully understand its contents including the risk and benefits of Telehealth therapy sessions*
Initial Here
Patient's Name*
Patient/Guardian Signature*

Clear
Legal Guardian Name/Association*
Date*

MonthDayYear
Date
Should be Empty:

New Patient Intake Information

New Patient Paperwork (Cash)

Informed Consent

Cancellation/No-Show Policy

Patient Consent for Telehealth Services