Stretch Therapy Informed Consent Form

The Risks

As Stretch therapy intends to resolve the problem that the person is experiencing due to illness or injury, some risks may arise, such as pain and discomfort during the therapy process. Stretching and twisting may cause some swelling and soreness of stiff muscles. This is normal. Some medicines may use hot or cold compresses to relieve the pain during treatment. Your physician may prescribe drugs to help you with the pain and swelling while undergoing Stretch therapy.

Please note that some can experience pain and discomfort that may reduce one's motivation to continue due to pain or lack of manifesting results. The person must continue the therapy if it is too early to conclude the results. It would be best to discuss these matters with your Stretch therapist.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name

PrefixFirst NameMiddle NameLast Name

Expectations

There are no guaranteed expectations when one undergoes Stretch therapy treatment. This depends on the situation. But when one undergoes a Stretch therapy program, it is intended that one will be able to return to his or her prior level of functioning or develop a method to continue what was possible to be performed before the injury that is no longer possible after being permanently injured. Stretch therapy

When going through the program, it is important that the patient is truthful with what he or she thinks or feels. Proper communication is important for the progress of the patient.

Confidentiality

Under the Healthcare Insurance Portability and Accountability Act of 1996 (“HIPPA”), we are required that all medical information of every individual be kept securely and shall not be disclosed to anyone. This allows the patient to have the right on how his or her information and how it shall be used.

The records we acquire from you shall be used for managing health care by health care providers and will be used for reference for payment or reimbursement for services such as billing or collection. We may also use your information for the assessment and improvement of our activities and business operations.

CONSENT

I have read all the information provided here or it has been read to me. I understand the contents of this informative consent form. I understand the risks involved in Stretch therapy and agree to participate in the procedures to be conducted and comply with the established plan of care set forth by my Stretch therapist. I have had the opportunity to ask questions and all of which were answered to me accordingly.

Consenting Age

I am of legal age and I give my full consent to the Stretch therapy treatment.I am below legal age and my parent or legal guardian gives his/her full consent to the Stretch therapy treatment for which I will undergo.

Date

Signature

Date

Signature

Name

First NameLast Name