I voluntarily consent to receive physical therapy evaluation and treatment from Haven Pelvic Health, LLC, provided by Dr. Emma Toillion, PT, DPT, a licensed physical therapist.

Nature of Physical Therapy
I understand that physical therapy is a healthcare service intended to assess and improve movement, strength, function, and overall physical well-being. Physical therapy services may include, but are not limited to:

• Evaluation of posture, movement patterns, strength, flexibility, and functional limitations
• Therapeutic exercise and activity-based interventions
• Manual therapy techniques applied to muscles, joints, or soft tissues
• Neuromuscular re-education and movement retraining
• Education related to posture, body mechanics, activity modification, and home exercise programs
• Use of heat, cold, or other non-invasive modalities when clinically appropriate

I understand that physical therapy may require active participation and that progress depends in part on my attendance, effort, and follow-through with recommendations.

Risks & Benefits
I understand that physical therapy may involve physical activity or hands-on techniques that could result in soreness, fatigue, or temporary discomfort. Potential benefits may include improved mobility, strength, coordination, function, and confidence with daily or recreational activities.

Patient Rights & Responsibilities

• I understand that I may ask questions about my care at any time
• I understand that I may decline or discontinue physical therapy treatment at any time
• I agree to communicate openly with my therapist regarding symptoms, concerns, or changes in my condition
• I understand that no guarantees have been made regarding specific outcomes or results

Separate Consent Acknowledgment
I understand that internal pelvic floor examination and/or treatment is not included in this general consent and requires a separate, specific informed consent.

By signing below, I acknowledge that I have read and understand this information, have had the opportunity to ask questions, and voluntarily consent to general physical therapy evaluation and treatment.

Effective date: 1/1/2026

Our Commitment to Your Privacy
Haven Pelvic Health, LLC is required by law to protect the privacy of your health information and to provide you with this Notice of Privacy Practices. This notice explains how your Protected Health Information (PHI) may be used and disclosed, and how you can access your information.

A more detailed Notice of Privacy Practices is available on our website or upon request.

How Your Health Information May Be Used
Your PHI may be used or disclosed, as permitted by law, for the following purposes:

• Treatment: To provide, coordinate, or manage your care (for example, sharing relevant information with another healthcare provider involved in your care)
• Payment: To process payments or prepare a superbill that you may submit to your insurance company for possible reimbursement
• Healthcare Operations: For practice operations such as documentation, quality improvement, recordkeeping, and compliance activities

We may also disclose information when required by law. Uses or disclosures outside of these purposes generally require your written authorization.

Your Rights Under HIPAA
You have the right to:

• Access and obtain a copy of your medical records
• Request corrections or amendments to your records
• Request restrictions on certain uses or disclosures
• Request confidential communications (such as alternative contact methods)
• Receive an accounting of certain disclosures
• Receive a paper copy of this Notice upon request
• File a complaint if you believe your privacy rights have been violated
• You will not be retaliated against for filing a complaint.

Our Responsibilities
We are required by law to:

• Maintain the privacy of your PHI
• Follow the terms of this Notice
• Notify you if a breach of unsecured PHI occurs

Questions or Complaints
If you have questions about this Notice or wish to file a privacy-related complaint, please contact:

Haven Pelvic Health, LLC
Privacy Contact: Emma Toillion, PT, DPT
Email: emma@havenpelvichealth.com
Phone: (252) 435-7871

You may also file a complaint with the U.S. Department of Health and Human Services.

Payment will be taken at the time of your visit.

The initial visit is $200 for a 75-minute evaluation ($175 for Paloma House members)

The following visits are $150 for 60-minute treatments

Payment plans can be set up at the time of the visit.